Healthcare Provider Details

I. General information

NPI: 1356152565
Provider Name (Legal Business Name): THE RETINA GROUP OF WASHINGTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 CORPORATE CENTER CT # 1F
WESTMINSTER MD
21157-3051
US

IV. Provider business mailing address

PO BOX 27780
BELFAST ME
04915-2029
US

V. Phone/Fax

Practice location:
  • Phone: 410-377-7611
  • Fax:
Mailing address:
  • Phone: 908-458-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEVEN A MADREPERLA
Title or Position: AO
Credential: MD
Phone: 908-458-8333