=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194725408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RETINA AND DIABETIC EYE SPECIALISTS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 07/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 N. BROADWAY
-----------------------------------------------------
City | PENNSVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08070-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-690-4900
-----------------------------------------------------
Fax | 610-690-1659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 STATE ROAD SUITE 206
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-690-4900
-----------------------------------------------------
Fax | 610-690-1659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATION
-----------------------------------------------------
Name | ANGELO VACIRCA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-690-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------