Healthcare Provider Details

I. General information

NPI: 1114721396
Provider Name (Legal Business Name): RETINA SPECIALISTS OF NEW YORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17017 NORTHERN BLVD
FLUSHING NY
11358-2709
US

IV. Provider business mailing address

17017 NORTHERN BLVD
FLUSHING NY
11358-2709
US

V. Phone/Fax

Practice location:
  • Phone: 718-539-6000
  • Fax: 718-539-4021
Mailing address:
  • Phone: 718-539-6000
  • Fax: 718-539-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GEORGE CONDAX
Title or Position: SECRETARY
Credential: MD
Phone: 718-539-6000