Basic Information
Provider Information | |||||||||
NPI: | 1194797795 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAMES A TAMMARO MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EYES OF ARIZONA VISION AND SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3360 | ||||||||
Address2: |   | ||||||||
City: | LAKE HAVASU CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 864053360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9288559477 | ||||||||
FaxNumber: | 9288551799 | ||||||||
Practice Location | |||||||||
Address1: | 40 CAPRI BLVD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | LAKE HAVASU CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 864035661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9288559477 | ||||||||
FaxNumber: | 9288551799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2006 | ||||||||
LastUpdateDate: | 12/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAMMARO | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9288559477 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 332B00000X | 05-08778 | AZ | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207W00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 03C0001024 | 01 | AZ | MEDICARE NSC | OTHER | 077182 | 05 | AZ |   | MEDICAID | AZ0200500 | 01 | AZ | BCBS | OTHER |