Provider Demographics
NPI:1952567794
Name:QUAD CITIES RETINA CONSULTANTS
Entity Type:Organization
Organization Name:QUAD CITIES RETINA CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANTARIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-326-8181
Mailing Address - Street 1:1230 E RUSHOLME ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2400
Mailing Address - Country:US
Mailing Address - Phone:563-326-8181
Mailing Address - Fax:563-326-8184
Practice Address - Street 1:1230 E RUSHOLME ST
Practice Address - Street 2:SUITE 107
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2400
Practice Address - Country:US
Practice Address - Phone:563-326-8181
Practice Address - Fax:563-326-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27394207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29346OtherMEDICARE ID- TYPE UNSPECIFIED
IA0293464Medicaid
IA0293464Medicaid