Healthcare Provider Details

I. General information

NPI: 1669018198
Provider Name (Legal Business Name): BASIM TALIANI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 E RAY RD
PHOENIX AZ
85044-6229
US

IV. Provider business mailing address

16122 108 ST NW
EDMONTON AB
T5X4Z7
CA

V. Phone/Fax

Practice location:
  • Phone: 602-760-0890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002399
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: