Healthcare Provider Details

I. General information

NPI: 1235729377
Provider Name (Legal Business Name): RETINA ASSOCIATES OF MID MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 E VEMERS FORD RD
COLUMBIA MO
65201-7465
US

IV. Provider business mailing address

11501 E VEMERS FORD RD
COLUMBIA MO
65201-7465
US

V. Phone/Fax

Practice location:
  • Phone: 573-228-0959
  • Fax:
Mailing address:
  • Phone: 573-228-0959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY R BLAIR
Title or Position: PHYSICIAN
Credential: MD, PHD
Phone: 573-874-1616