Healthcare Provider Details

I. General information

NPI: 1871775551
Provider Name (Legal Business Name): RETINA ASSOCIATES OF SARASOTA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 BEE RIDGE RD BLDG D
SARASOTA FL
34233-1207
US

IV. Provider business mailing address

3920 BEE RIDGE RD BLDG D
SARASOTA FL
34233-1207
US

V. Phone/Fax

Practice location:
  • Phone: 941-374-4491
  • Fax:
Mailing address:
  • Phone: 941-374-4491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME56535
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KEYE L WONG
Title or Position: PRESIDENT
Credential: MD
Phone: 941-374-4491