Provider Demographics
NPI:1811284946
Name:RETINA VITREOUS CENTER, PLLC
Entity type:Organization
Organization Name:RETINA VITREOUS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDEEP
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-607-6699
Mailing Address - Street 1:PO BOX 410108
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-0108
Mailing Address - Country:US
Mailing Address - Phone:405-607-6699
Mailing Address - Fax:405-607-6685
Practice Address - Street 1:1851 S KELLY AVE STE A
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3929
Practice Address - Country:US
Practice Address - Phone:405-607-6699
Practice Address - Fax:405-607-6685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-10
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200198330AMedicaid
WII57063Medicare UPIN
OK200198330AMedicaid
OKP00698367Medicare PIN