Provider Demographics
NPI:1962626945
Name:VITREO RETINAL ASSOCIATES PA
Entity Type:Organization
Organization Name:VITREO RETINAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAUSHIK
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAZARIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-371-2800
Mailing Address - Street 1:4340 W NEWBERRY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2586
Mailing Address - Country:US
Mailing Address - Phone:352-371-2800
Mailing Address - Fax:352-378-7009
Practice Address - Street 1:4340 W NEWBERRY RD STE 202
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2557
Practice Address - Country:US
Practice Address - Phone:352-371-2800
Practice Address - Fax:352-378-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50565Medicare UPIN
FLF40372Medicare UPIN