Healthcare Provider Details

I. General information

NPI: 1962626945
Provider Name (Legal Business Name): VITREO RETINAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 W NEWBERRY RD STE 202
GAINESVILLE FL
32607-2557
US

IV. Provider business mailing address

4340 W NEWBERRY RD SUITE 202
GAINESVILLE FL
32607-2586
US

V. Phone/Fax

Practice location:
  • Phone: 352-371-2800
  • Fax: 352-378-7009
Mailing address:
  • Phone: 352-371-2800
  • Fax: 352-378-7009

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. KAUSHIK M HAZARIWALA
Title or Position: PHYSICIAN
Credential: MD
Phone: 352-371-2800