=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134246853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTICUT RETINA CONSULTANTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 09/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 PRINCE STREET SUITE 203
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-787-6161
-----------------------------------------------------
Fax | 203-776-0300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 PRINCE STREET SUITE 203
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-787-6161
-----------------------------------------------------
Fax | 203-776-0300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/PHYSICIAN
-----------------------------------------------------
Name | WAYNE IAN LARRISON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 203-787-6161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 03754
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------