Healthcare Provider Details

I. General information

NPI: 1144806787
Provider Name (Legal Business Name): OPHTHALMOLOGY AND RETINA ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 05/02/2021
Certification Date: 05/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LAFAYETTE AVE
MOUNDSVILLE WV
26041-2345
US

IV. Provider business mailing address

PO BOX 315
NEW ALBANY OH
43054-0315
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-0908
  • Fax:
Mailing address:
  • Phone: 409-750-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTYN BILLINGS
Title or Position: CREDENTIALING
Credential:
Phone: 412-655-4362