MEDICARE: DR. TAMMY LAVICKA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1671	AZ

General Provider Information

NPI Number	:	1730321431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAMMY LAVICKA O.D.

Provider Business Mailing Address
First Line	:	6815 N 19TH AVE
Second Line	:	SUITE 130
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1134
Country	:	US
Telephone Number	:	602-242-5293
Fax Number	:

Provider Business Practice Location Address
First Line	:	6815 N 19TH AVE
Second Line	:	SUITE 130
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1134
Country	:	US
Telephone Number	:	602-242-5293
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2009
Last Update Date	:	05/05/2014

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