Healthcare Provider Details

I. General information

NPI: 1245679604
Provider Name (Legal Business Name): OCULIST EXCEPTIONAL EYEWEAR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5043-B N 7TH AVE
PHOENIX AZ
85013
US

IV. Provider business mailing address

5043-B N 7TH AVE
PHOENIX AZ
85013
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-0624
  • Fax:
Mailing address:
  • Phone: 602-266-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1738
License Number StateAZ

VIII. Authorized Official

Name: ANGELA MARQUEZ
Title or Position: DOCTOR
Credential: O.D.
Phone: 602-266-0624