Healthcare Provider Details

I. General information

NPI: 1497009641
Provider Name (Legal Business Name): PHOENIX OCULOPLASTIC CONSULTANTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 N 4TH AVE
PHOENIX AZ
85013-3905
US

IV. Provider business mailing address

4340 E INDIAN SCHOOL RD SUITE 21-440
PHOENIX AZ
85018-5360
US

V. Phone/Fax

Practice location:
  • Phone: 602-257-1499
  • Fax: 480-361-3517
Mailing address:
  • Phone: 602-257-1498
  • Fax: 480-361-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number33016
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number33016
License Number StateAZ

VIII. Authorized Official

Name: DR. MISHA FAUSTINA
Title or Position: MANAGER
Credential: M.D.
Phone: 602-257-1498