Healthcare Provider Details

I. General information

NPI: 1093970931
Provider Name (Legal Business Name): MATTHEW PALMER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 S STAPLEY DR
MESA AZ
85204-5013
US

IV. Provider business mailing address

2610 E UNIVERSITY DR
MESA AZ
85213-8436
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-9100
  • Fax: 480-833-6000
Mailing address:
  • Phone: 480-892-8400
  • Fax: 480-892-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1627
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: