Basic Information
| Provider Information | |||||||||
| NPI: | 1821168394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPE | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | WAGNER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAGNER | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 955 W SOUTHERN AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852104903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | 4808938172 | ||||||||
| Practice Location | |||||||||
| Address1: | 20928 N JOHN WAYNE PKWY STE C6 | ||||||||
| Address2: | |||||||||
| City: | MARICOPA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851392924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203164388 | ||||||||
| FaxNumber: | 5203164393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046008156 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT-002069 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.