Provider Demographics
NPI:1790141992
Name:RETINA, LLC
Entity Type:Organization
Organization Name:RETINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDDADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-797-2666
Mailing Address - Street 1:5800 COLONIAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5682
Mailing Address - Country:US
Mailing Address - Phone:954-975-0044
Mailing Address - Fax:
Practice Address - Street 1:5800 COLONIAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5682
Practice Address - Country:US
Practice Address - Phone:954-975-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 113019207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty