Basic Information
| Provider Information | |||||||||
| NPI: | 1780963611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA MACULAR DEGENERATION CENTER OF EXCELLENCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
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| 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: | 08/09/2011 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | CONWAY | ||||||||
| AuthorizedOfficialFirstName: | MANDI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6233636434 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.