MEDICARE: MARK PELLER OD AND ASSOCIATES PC

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	152WC0802X	Corneal and Contact Management Optometrist
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1528573508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK PELLER OD AND ASSOCIATES PC

Provider Business Mailing Address
First Line	:	220 N MCKEMY AVE
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85226-2654
Country	:	US
Telephone Number	:	480-835-4472
Fax Number	:	480-893-8172

Provider Business Practice Location Address
First Line	:	2279 N RAMPART BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7640
Country	:	US
Telephone Number	:	702-341-0118
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	VINCENT HAYES
Credential	:
Telephone Number	:	480-835-4470

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	12/12/2017

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