Healthcare Provider Details

I. General information

NPI: 1649928490
Provider Name (Legal Business Name): ATLANTIC RETINA CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E NASA BLVD STE 201
MELBOURNE FL
32901-1998
US

IV. Provider business mailing address

PO BOX 560095
ROCKLEDGE FL
32956-0095
US

V. Phone/Fax

Practice location:
  • Phone: 321-999-7456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HETAL VAISHNAV
Title or Position: OWNER
Credential: MD
Phone: 321-999-7456