Healthcare Provider Details

I. General information

NPI: 1669864641
Provider Name (Legal Business Name): JUSTIN MACKLIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 N 32ND ST STE 1
PHOENIX AZ
85032-7160
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-0054
  • Fax: 602-788-8431
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-001991
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: