Provider Demographics
NPI:1306293964
Name:PACIFIC RETINA
Entity type:Organization
Organization Name:PACIFIC RETINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-943-6800
Mailing Address - Street 1:122 LA CASA VIA
Mailing Address - Street 2:#223
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3052
Mailing Address - Country:US
Mailing Address - Phone:925-943-6800
Mailing Address - Fax:925-943-6880
Practice Address - Street 1:122 LA CASA VIA
Practice Address - Street 2:#223
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3052
Practice Address - Country:US
Practice Address - Phone:925-943-6800
Practice Address - Fax:925-943-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty