Basic Information
| Provider Information | |||||||||
| NPI: | 1053765370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIONWIDE OPTOMETRY P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | 4808938172 | ||||||||
| Practice Location | |||||||||
| Address1: | 5405 E GRANITE ST | ||||||||
| Address2: | BLDG. 2527 | ||||||||
| City: | DAVIS MONTHAN AFB | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857073004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207455669 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4808354470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 1326472945 | 01 | AZ | BILLING NPI | OTHER |