1154132488 NPI number — THE RETINA GROUP OF WASHINGTON, PLLC

Table of content: (NPI 1154132488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154132488 NPI number — THE RETINA GROUP OF WASHINGTON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE RETINA GROUP OF WASHINGTON, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154132488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27780
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-2029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-458-8333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 DAISY REID AVE FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-5598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-468-4887
Provider Business Practice Location Address Fax Number:
703-590-2288
Provider Enumeration Date:
01/16/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MADREPERLA
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
908-458-8333

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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