Healthcare Provider Details

I. General information

NPI: 1356377873
Provider Name (Legal Business Name): PHOENIX OPHTHALMOLOGISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E MISSOURI AVE STE 100
PHOENIX AZ
85014-2712
US

IV. Provider business mailing address

1130 E MISSOURI AVE STE 100
PHOENIX AZ
85014-2712
US

V. Phone/Fax

Practice location:
  • Phone: 602-995-1166
  • Fax: 602-995-1166
Mailing address:
  • Phone: 602-995-1166
  • Fax: 602-995-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number41479
License Number StateAZ

VIII. Authorized Official

Name: DR. JEREMY VANBUREN
Title or Position: MD
Credential: MD
Phone: 602-995-1166