Provider Demographics
NPI:1255452603
Name:RETINA & VITREOUS CONSULTANTS INC
Entity type:Organization
Organization Name:RETINA & VITREOUS CONSULTANTS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-367-1278
Mailing Address - Street 1:1600 S BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1320
Mailing Address - Country:US
Mailing Address - Phone:314-367-1278
Mailing Address - Fax:314-968-5117
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 1625
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-881-1211
Practice Address - Fax:314-727-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty