Basic Information
| Provider Information | |||||||||
| NPI: | 1558470583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZYZ | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42201 N 41ST DR | ||||||||
| Address2: | SUITE 144 | ||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850863800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235519122 | ||||||||
| FaxNumber: | 6235519120 | ||||||||
| Practice Location | |||||||||
| Address1: | 42201 N 41ST DR | ||||||||
| Address2: | SUITE 124-128 | ||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850863800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235519122 | ||||||||
| FaxNumber: | 6235519120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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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 | 152W00000X | 1146 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 1146 | AZ | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | 1146 | AZ | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | AZ0903340 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER |