Healthcare Provider Details

I. General information

NPI: 1447690607
Provider Name (Legal Business Name): ALISON DOMENICA KITZEROW OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

IV. Provider business mailing address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-1000
  • Fax:
Mailing address:
  • Phone: 602-955-1000
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ 2038
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002755
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: