Provider Demographics
NPI:1982888988
Name:CAPITAL REGION RETINA, PLLC
Entity Type:Organization
Organization Name:CAPITAL REGION RETINA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ATERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:518-437-1111
Mailing Address - Street 1:1365 WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1068
Mailing Address - Country:US
Mailing Address - Phone:518-437-1111
Mailing Address - Fax:518-435-1114
Practice Address - Street 1:1365 WASHINGTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1068
Practice Address - Country:US
Practice Address - Phone:518-437-1111
Practice Address - Fax:518-435-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01482508Medicaid