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General NPI Number Information
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NPI Number | 1265201925
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Entity Type | Individual
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Provider Name | DER VANG OD
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Gender | Female
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Dates
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Enumeration Date | 12/22/2023
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Last Update Date | 09/18/2024
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Provider Practice Location Address
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Address Line | 15003 W BELL RD STE 100
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City | SURPRISE
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State | AZ
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Zip | 85374-3244
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Country | US
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Telephone | 623-931-2943
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Fax | 623-583-2253
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Provider Business Mailing Address
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Address Line | 26031 N 53RD DR
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City | PHOENIX
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State | AZ
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Zip | 85083-6349
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Country | US
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Telephone | 559-387-9155
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT-002741
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License Number State | AZ
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