Basic Information
| Provider Information | |||||||||
| NPI: | 1528573508 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK PELLER OD AND ASSOCIATES PC | ||||||||
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| OtherOrganizationName: | NATIONWIDE OPTOMETRY OF NEVADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808354472 | ||||||||
| FaxNumber: | 4808938172 | ||||||||
| Practice Location | |||||||||
| Address1: | 2279 N RAMPART BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891287640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023410118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2017 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4808354470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.