Healthcare Provider Details

I. General information

NPI: 1093999609
Provider Name (Legal Business Name): RETINA & VITREOUS L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53822 GENERATIONS DRIVE
SOUTH BEND IN
46635-1543
US

IV. Provider business mailing address

53822 GENERATIONS DRIVE
SOUTH BEND IN
46635-1543
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-3711
  • Fax: 574-288-1702
Mailing address:
  • Phone: 574-233-3711
  • Fax: 574-288-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT T LEE
Title or Position: PARTNER
Credential: MD
Phone: 574-233-3711