Organization
RETINA & VITREOUS L L C
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROBERT T LEE MD (PARTNER)
(574) 233-3711
Entity
Organization
Contact information
Practice address
53822 GENERATIONS DRIVE, SOUTH BEND, IN 46635-1543
(574) 233-3711
(574) 288-1702
Mailing address
53822 GENERATIONS DRIVE, SOUTH BEND, IN 46635-1543
(574) 233-3711
(574) 288-1702
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
—
—
207WX0107X
Retina Specialist (Ophthalmology) Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000549277
ANTHEM
IN
05
—
200883090
—
IN
Enumeration date
12/19/2007
Last updated
07/12/2017
Update your record
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