Provider Demographics
NPI:1154314292
Name:SOUTHERN RETINA CONSULTANTS PSC
Entity type:Organization
Organization Name:SOUTHERN RETINA CONSULTANTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:GUTIERREZ-DORRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-842-2512
Mailing Address - Street 1:PO BOX 801089
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1089
Mailing Address - Country:US
Mailing Address - Phone:787-842-2512
Mailing Address - Fax:787-840-6966
Practice Address - Street 1:909 AVE TITO CASTRO
Practice Address - Street 2:SUITE 709
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4728
Practice Address - Country:US
Practice Address - Phone:787-842-2512
Practice Address - Fax:787-840-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11622207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61738Medicare UPIN
90035Medicare PIN