Healthcare Provider Details

I. General information

NPI: 1790141992
Provider Name (Legal Business Name): RETINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 COLONIAL DR SUITE 300
MARGATE FL
33063-5682
US

IV. Provider business mailing address

5800 COLONIAL DR SUITE 300
MARGATE FL
33063-5682
US

V. Phone/Fax

Practice location:
  • Phone: 954-975-0044
  • Fax:
Mailing address:
  • Phone: 954-975-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME 113019
License Number StateFL

VIII. Authorized Official

Name: RAM PEDDADA
Title or Position: OWNER
Credential: MD
Phone: 307-797-2666