Provider Demographics
NPI:1932500634
Name:ESTERO RETINA
Entity Type:Organization
Organization Name:ESTERO RETINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-713-2126
Mailing Address - Street 1:8951 BONITA BEACH RD SE STE 525-298
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4201
Mailing Address - Country:US
Mailing Address - Phone:321-222-3937
Mailing Address - Fax:
Practice Address - Street 1:9500 CORKSCREW PALMS CIR
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3307
Practice Address - Country:US
Practice Address - Phone:321-222-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105560207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty