Healthcare Provider Details

I. General information

NPI: 1962480764
Provider Name (Legal Business Name): ROBERT JACK MAYNARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W CAMELBACK RD SUITE 1
PHOENIX AZ
85013-2563
US

IV. Provider business mailing address

114 W CAMELBACK RD SUITE 1
PHOENIX AZ
85013-2563
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-4104
  • Fax: 602-241-0687
Mailing address:
  • Phone: 602-264-4104
  • Fax: 602-241-0687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number145
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: