MEDICARE: DR. MARK LAWRENCE JAFFE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	114	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00360908	OTHER	AZ	RAIL ROAD MEDICARE

General Provider Information

NPI Number	:	1093717373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK LAWRENCE JAFFE O.D.

Provider Business Mailing Address
First Line	:	6404 W WETHERSFIELD RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1630
Country	:	US
Telephone Number	:	623-878-8538
Fax Number	:	623-878-8538

Provider Business Practice Location Address
First Line	:	6666 W PEORIA AVE
Second Line	:	STE 109
City	:	GLENDALE
State	:	AZ
Zip	:	85302-7032
Country	:	US
Telephone Number	:	623-979-8876
Fax Number	:	623-979-2811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/02/2008

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