Provider Demographics
NPI:1134246853
Name:CONNECTICUT RETINA CONSULTANTS LLC
Entity type:Organization
Organization Name:CONNECTICUT RETINA CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:LARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-787-6161
Mailing Address - Street 1:46 PRINCE STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1600
Mailing Address - Country:US
Mailing Address - Phone:203-787-6161
Mailing Address - Fax:203-776-0300
Practice Address - Street 1:46 PRINCE STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1600
Practice Address - Country:US
Practice Address - Phone:203-787-6161
Practice Address - Fax:203-776-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03754207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004203163Medicaid
CT180040407OtherRAILROAD MEDICARE
CT001307546Medicaid
CTP00412496OtherMEDICARE RAIL ROAD
CT180042135OtherRAILROAD MEDICARE
CTCH2721OtherRAILROAD MEDICARE
CT001367300Medicaid
CT001337303Medicaid
CT180040406OtherRAILROAD MEDICARE
CT180042135OtherRAILROAD MEDICARE
CTP00412496OtherMEDICARE RAIL ROAD
CT001307546Medicaid
CT180040407OtherRAILROAD MEDICARE
CTC02602Medicare PIN
CT180000880Medicare PIN
CT180000879Medicare PIN
CTCH2721OtherRAILROAD MEDICARE
CTG37757Medicare UPIN
CTE62963Medicare UPIN