Provider Demographics
NPI:1083580815
Name:FOUR STATES RETINA PLLC
Entity type:Organization
Organization Name:FOUR STATES RETINA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-647-2381
Mailing Address - Street 1:5501 MEDICAL PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4624
Mailing Address - Country:US
Mailing Address - Phone:804-647-2381
Mailing Address - Fax:903-209-2893
Practice Address - Street 1:5501 MEDICAL PARKWAY DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4624
Practice Address - Country:US
Practice Address - Phone:804-647-2381
Practice Address - Fax:903-209-2893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty