MEDICARE: TRI-STATE RETINA P.C.

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
1	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NONE

General Provider Information

NPI Number	:	1396206306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE RETINA P.C.

Provider Business Mailing Address
First Line	:	PO BOX 15
Second Line	:
City	:	SCARSDALE
State	:	NY
Zip	:	10583-0015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	559 GRAMATAN AVE STE 202
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10552-2156
Country	:	US
Telephone Number	:	914-699-2020
Fax Number	:	914-699-2019

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAVI RADHAKRISHNAN
Credential	:	MD
Telephone Number	:	914-699-2020

Provider Enumeration Date	:	03/31/2019
Last Update Date	:	01/06/2025

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