Provider Demographics
NPI:1881754273
Name:CAPITAL RETINA ASSOCIATES, PLLC
Entity type:Organization
Organization Name:CAPITAL RETINA ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAYRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:518-785-1100
Mailing Address - Street 1:1399 NEW SCOTLAND ROAD
Mailing Address - Street 2:PO BOX 129
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-0129
Mailing Address - Country:US
Mailing Address - Phone:518-785-1100
Mailing Address - Fax:518-785-1109
Practice Address - Street 1:7D JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-3003
Practice Address - Country:US
Practice Address - Phone:518-785-1100
Practice Address - Fax:518-785-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171638174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE56788Medicare UPIN
NYBA0622Medicare PIN