Basic Information
| Provider Information | |||||||||
| NPI: | 1790972388 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YUMA VISION CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2750 S PACIFIC AVE STE D | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853653547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287827557 | ||||||||
| FaxNumber: | 9287838445 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 S PACIFIC AVE STE D | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853653547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287827557 | ||||||||
| FaxNumber: | 9287838445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DETERMAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | FRANCES | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR OF OPTOMETRY | ||||||||
| AuthorizedOfficialTelephone: | 9287827557 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 663 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 786 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 104927 | 05 | AZ | MEDICAID | 074667 | 05 | AZ | MEDICAID |