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General NPI Number Information
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NPI Number | 1811284946
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Entity Type | Organization
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Legal Business Name | RETINA VITREOUS CENTER, PLLC
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Dates
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Enumeration Date | 07/10/2011
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 1851 S KELLY AVE STE A
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City | EDMOND
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State | OK
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Zip | 73013-3929
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Country | US
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Telephone | 405-607-6699
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Fax | 405-607-6685
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Provider Business Mailing Address
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Address Line | PO BOX 410108
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City | KANSAS CITY
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State | MO
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Zip | 64141-0108
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Country | US
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Telephone | 405-607-6699
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Fax | 405-607-6685
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Authorized Official
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Title or Position | FOUNDING MANAGER
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Name | DR. SANDEEP N. SHAH
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Credential | M.D.
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Telephone | 405-607-6699
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number |
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License Number State |
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