Healthcare Provider Details

I. General information

NPI: 1891783965
Provider Name (Legal Business Name): VITREO RETINAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 09/02/2025
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 76TH ST STE 300
EDINA MN
55435-6215
US

IV. Provider business mailing address

3601 W 76TH ST STE 300
EDINA MN
55435-3004
US

V. Phone/Fax

Practice location:
  • Phone: 952-929-1131
  • Fax: 952-897-1178
Mailing address:
  • Phone: 952-929-1131
  • Fax: 952-897-1178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. GRETCHEN G POFFENBERGER
Title or Position: CFO
Credential:
Phone: 952-897-1175