Basic Information
| Provider Information | |||||||||
| NPI: | 1902052855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAKOSHI | ||||||||
| FirstName: | GHADEER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | O.D.,F.A.A.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 1681 | AZ | Y | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WP0200X | 2008023450 | MO | N | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Z144717 | 01 | AZ | MEDICARE PTAN | OTHER |