Healthcare Provider Details

I. General information

NPI: 1770734451
Provider Name (Legal Business Name): RETINOVITREOUS ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 MEDICAL CROSSING RD
TAMAQUA PA
18252-5565
US

IV. Provider business mailing address

4060 BUTLER PIKE STE 200
PLYMOUTH MEETING PA
19462-1560
US

V. Phone/Fax

Practice location:
  • Phone: 570-386-5926
  • Fax:
Mailing address:
  • Phone: 800-331-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY SHEPPARD
Title or Position: CFO/CAP
Credential:
Phone: 800-331-6634