Healthcare Provider Details

I. General information

NPI: 1518531649
Provider Name (Legal Business Name): VIRATA RETINA CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
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 Number
License Number State

VIII. Authorized Official

Name: STEVEN R VIRATA
Title or Position: OWNER
Credential: MD
Phone: 765-573-8462