Healthcare Provider Details

I. General information

NPI: 1902133739
Provider Name (Legal Business Name): I DRS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42201 N 41ST DR SUITE 144
ANTHEM AZ
85086-3800
US

IV. Provider business mailing address

42201 N 41ST DR SUITE 144
ANTHEM AZ
85086-3800
US

V. Phone/Fax

Practice location:
  • Phone: 623-551-9122
  • Fax: 623-551-9120
Mailing address:
  • Phone: 623-551-9122
  • Fax: 623-551-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1174
License Number StateAZ

VIII. Authorized Official

Name: DR. DAVID PAUL SHIBATA
Title or Position: PRESIDENT
Credential: O.D.
Phone: 623-551-9122