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General NPI Number Information
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NPI Number | 1619272101
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Entity Type | Organization
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Legal Business Name | CENTRAL PIEDMONT RETINA
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Dates
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Enumeration Date | 01/14/2011
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Last Update Date | 01/14/2011
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Provider Practice Location Address
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Address Line | 3333 BROOKVIEW HILLS BLVD SUITE 201
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City | WINSTON SALEM
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State | NC
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Zip | 27103-5661
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Country | US
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Telephone | 336-602-2801
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Fax | 336-602-2804
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Provider Business Mailing Address
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Address Line | 3333 BROOKVIEW HILLS BLVD SUITE 201
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City | WINSTON SALEM
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State | NC
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Zip | 27103-5661
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Country | US
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Telephone | 336-602-2801
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Fax | 336-602-2804
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Authorized Official
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Title or Position | CEO
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Name | JOHN HARRIOTT
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Credential | M.D.
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Telephone | 336-602-2801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 28868
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License Number State | NC
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