Provider Demographics
NPI:1194725408
Name:RETINA AND DIABETIC EYE SPECIALISTS PA
Entity type:Organization
Organization Name:RETINA AND DIABETIC EYE SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:VACIRCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-690-4900
Mailing Address - Street 1:130 STATE ROAD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1232
Mailing Address - Country:US
Mailing Address - Phone:610-690-4900
Mailing Address - Fax:610-690-1659
Practice Address - Street 1:48 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1754
Practice Address - Country:US
Practice Address - Phone:610-690-4900
Practice Address - Fax:610-690-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA524894Medicare ID - Type Unspecified