Healthcare Provider Details

I. General information

NPI: 1598889891
Provider Name (Legal Business Name): QUINT DI GIACOMO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W HILL AVE
GALLUP NM
87301-6218
US

IV. Provider business mailing address

10025 E DYNAMITE BLVD STE 115
SCOTTSDALE AZ
85262-3688
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2289
  • Fax: 505-726-6208
Mailing address:
  • Phone: 480-419-7778
  • Fax: 480-419-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP2281
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01246
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: