Healthcare Provider Details

I. General information

NPI: 1063526713
Provider Name (Legal Business Name): TOTAL RETINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6115 FALLS RD SUITE 300
BALTIMORE MD
21209-2219
US

IV. Provider business mailing address

6115 FALLS RD SUITE 300
BALTIMORE MD
21209-2219
US

V. Phone/Fax

Practice location:
  • Phone: 410-377-9004
  • Fax: 410-377-8221
Mailing address:
  • Phone: 410-377-9004
  • Fax: 410-377-8221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0041207
License Number StateMD

VIII. Authorized Official

Name: RANDALL V WONG
Title or Position: PRESIDENT
Credential: MD
Phone: 410-377-9004