Provider Demographics
NPI:1215068770
Name:RETINA CENTER OF VERMONT, INC
Entity type:Organization
Organization Name:RETINA CENTER OF VERMONT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISSGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-864-3937
Mailing Address - Street 1:99 SWIFT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7303
Mailing Address - Country:US
Mailing Address - Phone:802-864-3937
Mailing Address - Fax:802-864-3936
Practice Address - Street 1:99 SWIFT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7303
Practice Address - Country:US
Practice Address - Phone:802-864-3937
Practice Address - Fax:802-864-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011807Medicaid
VTREVN3845Medicare ID - Type Unspecified