Provider Demographics
NPI:1336193994
Name:DELAWARE VALLEY RETINA ASSOCIATES PC
Entity Type:Organization
Organization Name:DELAWARE VALLEY RETINA ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARMAKUSUMA
Authorized Official - Middle Name:
Authorized Official - Last Name:IE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-896-1414
Mailing Address - Street 1:4 PRINCESS RD
Mailing Address - Street 2:BUILDING 100, SUITE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-896-1414
Mailing Address - Fax:609-896-2982
Practice Address - Street 1:4 PRINCESS RD
Practice Address - Street 2:BUILDING 100, SUITE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-896-1414
Practice Address - Fax:609-896-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACI9131OtherRAILROAD MEDICARE
NJCC5703OtherRAILROAD MEDICARE
NJ1336193994OtherCHAMPUS/TRICARE PGBA
NJCI9130OtherRAILROAD MEDICARE
NJCI9130OtherRAILROAD MEDICARE
NJCC5703OtherRAILROAD MEDICARE