Basic Information
| Provider Information | |||||||||
| NPI: | 1932525334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RETINA MACULA SPECIALISTS OF MIAMI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 NE 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331623412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056550411 | ||||||||
| FaxNumber: | 3056550499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1385 CORAL WAY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331452941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058582228 | ||||||||
| FaxNumber: | 3056536300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3056536500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME86697 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 269577407 | 05 | FL | MEDICAID |