Healthcare Provider Details

I. General information

NPI: 1710212782
Provider Name (Legal Business Name): VITREO-RETINAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 N TRACY BLVD
TRACY CA
95376-2903
US

IV. Provider business mailing address

3939 J ST SUITE 104
SACRAMENTO CA
95819-3631
US

V. Phone/Fax

Practice location:
  • Phone: 916-454-4861
  • Fax: 916-454-3603
Mailing address:
  • Phone: 916-454-6191
  • Fax: 916-454-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT WENDEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 916-453-5450