Healthcare Provider Details

I. General information

NPI: 1821457532
Provider Name (Legal Business Name): OCULOPLASTIC EYE SURGEONS OF PHOENIX P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2016
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: 623-522-8683
Mailing address:
  • Phone: 480-788-1134
  • Fax: 623-522-8683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LISA DIANNE MIHORA
Title or Position: OWNER
Credential: M.D.
Phone: 480-788-1134