Provider Demographics
NPI:1861525305
Name:MANDELL RETINA CENTER PC
Entity type:Organization
Organization Name:MANDELL RETINA CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-227-4300
Mailing Address - Street 1:397 LITTLE NECK RD
Mailing Address - Street 2:3300 SOUTH BUILDING SUITE 202
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5765
Mailing Address - Country:US
Mailing Address - Phone:757-227-4300
Mailing Address - Fax:757-486-3125
Practice Address - Street 1:397 LITTLE NECK RD
Practice Address - Street 2:3300 SOUTH BUILDING SUITE 202
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-5765
Practice Address - Country:US
Practice Address - Phone:757-227-4300
Practice Address - Fax:757-486-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10134OtherMEDICARE