Provider Demographics
NPI:1730191800
Name:VITREO-RETINAL ASSOCIATES MEDICAL GROUP
Entity type:Organization
Organization Name:VITREO-RETINAL ASSOCIATES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KONDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-440-9920
Mailing Address - Street 1:800 FAIRMOUNT AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3151
Mailing Address - Country:US
Mailing Address - Phone:626-440-9920
Mailing Address - Fax:626-440-0351
Practice Address - Street 1:160 E ARTESIA BLVD
Practice Address - Street 2:SUITE 345
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2922
Practice Address - Country:US
Practice Address - Phone:909-865-7990
Practice Address - Fax:909-865-0931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITREO-RETINAL ASSOCIATES MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-13
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACS9651OtherMEDICARE RAILROAD
W11190AOtherMEDICARE
CA180003746OtherMEDICARE RAILROAD
CAGR0046201Medicaid