Healthcare Provider Details

I. General information

NPI: 1144069030
Provider Name (Legal Business Name): THE RETINA GROUP OF WASHINGTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5283 CORPORATE DR STE 201
FREDERICK MD
21703-2879
US

IV. Provider business mailing address

420 MOUNTAIN AVE FL 4
NEW PROVIDENCE NJ
07974-2736
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-4545
  • Fax:
Mailing address:
  • Phone: 908-458-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN MADREPERLA
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 908-458-8333