Healthcare Provider Details

I. General information

NPI: 1639252000
Provider Name (Legal Business Name): RETINA & VITREOUS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2006
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 KEMPSVILLE CIR STE 120B
NORFOLK VA
23502-3933
US

IV. Provider business mailing address

6160 KEMPSVILLE CIR STE 250B
NORFOLK VA
23502-3933
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-4400
  • Fax: 757-481-1285
Mailing address:
  • Phone: 757-481-4400
  • Fax: 757-481-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101039260
License Number StateVA

VIII. Authorized Official

Name: ALAN L. WAGNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 757-481-4400