MEDICARE: THOMAS R CZYZ 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	1146	AZ
2	152WC0802X	Corneal and Contact Management Optometrist	1146	AZ
3	152WL0500X	Low Vision Rehabilitation Optometrist	1146	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0903340	OTHER	AZ	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558470583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS R CZYZ O.D.

Provider Business Mailing Address
First Line	:	42201 N 41ST DR
Second Line	:	SUITE 144
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3800
Country	:	US
Telephone Number	:	623-551-9122
Fax Number	:	623-551-9120

Provider Business Practice Location Address
First Line	:	42201 N 41ST DR
Second Line	:	SUITE 124-128
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3800
Country	:	US
Telephone Number	:	623-551-9122
Fax Number	:	623-551-9120

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/17/2014

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