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NPI Code Detail

MEDICARE: FOUR STATES RETINA PLLC

MEDICARE: FOUR STATES RETINA PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207WX0107XRetina Specialist (Ophthalmology) Physician

General Provider Information

NPI Number : 1083580815
Entity Type Code : Organization
Provider Name (Legal Business Name) : FOUR STATES RETINA PLLC
Provider Business Mailing Address
First Line : 5501 MEDICAL PARKWAY DR
Second Line :
City : TEXARKANA
State : TX
Zip : 75503-4624
Country : US
Telephone Number : 903-204-7642
Fax Number : 903-204-7745
Provider Business Practice Location Address
First Line : 5501 MEDICAL PARKWAY DR
Second Line :
City : TEXARKANA
State : TX
Zip : 75503-4624
Country : US
Telephone Number : 804-647-2381
Fax Number : 903-204-7745
Authorized Official
Title or Position : OWNER
Name : ROSHAN GEORGE
Credential : MD
Telephone Number : 903-204-7642
Provider Enumeration Date : 10/17/2025
Last Update Date : 02/19/2026

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