Basic Information
| Provider Information | |||||||||
| NPI: | 1225038946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEYMAN | ||||||||
| FirstName: | GHOLAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853754401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743937 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Practice Location | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853754401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743937 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 31729 | AZ | N | 207W00000X | 31729 | AZ | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 111874 | 05 | AZ | MEDICAID |