Basic Information
| Provider Information | |||||||||
| NPI: | 1487845764 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARIZONA INSTITUTE OF EYE SURGERY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRESCOTT VISION & EYE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3192 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287783950 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3192 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287783950 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARKHAM | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9287783950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | OSC4258 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 207W00000X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 033176-001 | 01 | MERCYCARE | OTHER | DM2NNP | 01 | ARIZONA FOUNDATION | OTHER | 03-C0001215 | 01 | AZ | MEDICARE CCN | OTHER | 3421045 | 01 | CIGNA | OTHER | 572818 | 01 | RAN & AMN | OTHER | 2Z6546 | 01 | HEALTHNET | OTHER | 4498 | 01 | AZ | PHYSICIAN MEDICAL LICENSE | OTHER | 866291-9714 | 01 | HUMANA | OTHER | 280244 | 05 | AZ | MEDICAID | 190721 | 05 | AZ | MEDICAID | 7442967 | 01 | AETNA | OTHER |