Provider Demographics
NPI:1902800758
Name:RETINA CONSULTANTS, PLLC
Entity Type:Organization
Organization Name:RETINA CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:DUNDERVILL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:304-346-4400
Mailing Address - Street 1:PO BOX 3970
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-3970
Mailing Address - Country:US
Mailing Address - Phone:304-346-4400
Mailing Address - Fax:304-346-0704
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:STE 301
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1605
Practice Address - Country:US
Practice Address - Phone:304-346-4400
Practice Address - Fax:304-346-0704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002207W00000X
WV207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008255000Medicaid
OH0939668Medicaid
KY65927964Medicaid
KY65927964Medicaid
CL4887Medicare PIN