Healthcare Provider Details

I. General information

NPI: 1477603074
Provider Name (Legal Business Name): VITREORETINAL EYE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 TOMMY MUNRO DR STE E
BILOXI MS
39532-2139
US

IV. Provider business mailing address

962 TOMMY MUNRO DR STE E
BILOXI MS
39532-2139
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-7000
  • Fax: 833-849-9899
Mailing address:
  • Phone: 228-388-7000
  • Fax: 833-849-9899

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 Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number17239
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number023984
License Number StateLA

VIII. Authorized Official

Name: DR. AVIT J GREMILLION
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 228-388-7000