Provider Demographics
NPI:1851686968
Name:MIDWEST EYE RETINA PC
Entity Type:Organization
Organization Name:MIDWEST EYE RETINA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:K
Authorized Official - Last Name:MATURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-817-1414
Mailing Address - Street 1:200 W 103RD ST
Mailing Address - Street 2:SUITE 1060
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1007
Mailing Address - Country:US
Mailing Address - Phone:317-817-1414
Mailing Address - Fax:
Practice Address - Street 1:200 W 103RD ST
Practice Address - Street 2:SUITE 1060
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1007
Practice Address - Country:US
Practice Address - Phone:317-805-2200
Practice Address - Fax:317-805-4579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065433A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201035490Medicaid
IN201035490Medicaid