Healthcare Provider Details

I. General information

NPI: 1487628699
Provider Name (Legal Business Name): STEVEN R VIRATA MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PROFESSIONAL CT STE A
LAFAYETTE IN
47905-5153
US

IV. Provider business mailing address

150 PROFESSIONAL CT STE A
LAFAYETTE IN
47905-5153
US

V. Phone/Fax

Practice location:
  • Phone: 765-573-8462
  • Fax:
Mailing address:
  • Phone: 765-573-8462
  • Fax: 765-767-4818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number01054616A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: