Basic Information
| Provider Information | |||||||||
| NPI: | 1104090737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN R. MARKHAM PC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRESCOTT VISION & EYE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287783950 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 PALOMINO ROAD | ||||||||
| Address2: | |||||||||
| City: | CHINO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286365504 | ||||||||
| FaxNumber: | 9286360780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARKHAM | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9287783950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | AZ | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 033176 | 05 | AZ | MEDICAID | 15220 | 01 | AVESIS | OTHER | 0384690001 | 01 | DMERC OPTICAL SUPPLIER - PRESCOTT | OTHER | AZ01170 | 01 | MEDICARE SUBMITTER ID - PRESCOTT | OTHER | 5858351 | 01 | AETNA | OTHER | 190721 | 05 | AZ | MEDICAID | 866291-9714 | 01 | HUMANA | OTHER |