Basic Information
Provider Information | |||||||||
NPI: | 1023503810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ESQUIBEL | ||||||||
FirstName: | ARIEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALKER | ||||||||
OtherFirstName: | ARIEL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 920 HARROD WAY | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864015339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287273220 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 383 LAKE HAVASU AVE S | ||||||||
Address2: |   | ||||||||
City: | LAKE HAVASU CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 864039368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286801144 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2018 | ||||||||
LastUpdateDate: | 09/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT34381-TLG | CA | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | OPT-002324 | AZ | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.