Healthcare Provider Details

I. General information

NPI: 1225094550
Provider Name (Legal Business Name): JOHN R MARKHAM O D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 WILLOW CREEK RD
PRESCOTT AZ
86301-1108
US

IV. Provider business mailing address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

V. Phone/Fax

Practice location:
  • Phone: 928-778-3950
  • Fax: 928-778-3999
Mailing address:
  • Phone: 928-778-3950
  • Fax: 928-778-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number142
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: