Provider Demographics
NPI:1528303849
Name:RETINA INSTITUTE, PLLC
Entity type:Organization
Organization Name:RETINA INSTITUTE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-228-6262
Mailing Address - Street 1:4300 TALBOT RD S STE 300
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-228-6262
Mailing Address - Fax:425-228-6260
Practice Address - Street 1:4300 TALBOT RD S STE 300
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6238
Practice Address - Country:US
Practice Address - Phone:425-228-6262
Practice Address - Fax:425-228-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60021230207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1528303849OtherMEDICARE NPI
WA2026169Medicaid