Healthcare Provider Details

I. General information

NPI: 1639168255
Provider Name (Legal Business Name): LISA DIANNE MIHORA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9151 W THUNDERBIRD RD # G104
PEORIA AZ
85381-4906
US

IV. Provider business mailing address

9151 W THUNDERBIRD RD # G104
PEORIA AZ
85381-4906
US

V. Phone/Fax

Practice location:
  • Phone: 623-522-8687
  • Fax: 862-522-8683
Mailing address:
  • Phone: 623-522-8687
  • Fax: 623-522-8683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number44635
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number44635
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: