Healthcare Provider Details

I. General information

NPI: 1043297385
Provider Name (Legal Business Name): RETINA CENTER OF WESTERN MARYLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E BALTIMORE ST LOWER LEVEL
HAGERSTOWN MD
21740-6144
US

IV. Provider business mailing address

251 E BALTIMORE ST LOWER LEVEL
HAGERSTOWN MD
21740-6144
US

V. Phone/Fax

Practice location:
  • Phone: 301-416-8600
  • Fax: 301-416-8602
Mailing address:
  • Phone: 301-416-8600
  • Fax: 301-416-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0052418
License Number StateMD

VIII. Authorized Official

Name: DARA TASH
Title or Position: CEO
Credential: MD
Phone: 301-416-8600