Healthcare Provider Details

I. General information

NPI: 1104873223
Provider Name (Legal Business Name): PHILADELPHIA RETINA ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 HOLME AVE STE 303
PHILADELPHIA PA
19152-2029
US

IV. Provider business mailing address

2701 HOLME AVE SUITE 303
PHILADELPHIA PA
19152-2029
US

V. Phone/Fax

Practice location:
  • Phone: 215-335-3088
  • Fax: 215-335-0315
Mailing address:
  • Phone: 215-335-3088
  • Fax: 215-335-0315

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: EDWARD A DEQLIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 215-335-3088