Healthcare Provider Details

I. General information

NPI: 1366803538
Provider Name (Legal Business Name): OCULOPLASTIC EYE SURGEONS OF PHOENIX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 E BELL RD SUITE 106
PHOENIX AZ
85032-2138
US

IV. Provider business mailing address

22320 N 59TH LN
GLENDALE AZ
85310-4264
US

V. Phone/Fax

Practice location:
  • Phone: 480-788-1134
  • Fax:
Mailing address:
  • Phone: 480-788-1134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number44635
License Number StateAZ

VIII. Authorized Official

Name: LISA D MIHORA
Title or Position: OWNER
Credential: M.D.
Phone: 480-788-1134