Provider Demographics
NPI:1003812256
Name:FRISKE, TAMI CORDT (OD)
Entity Type:Individual
Prefix:DR
First Name:TAMI
Middle Name:CORDT
Last Name:FRISKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 N LITTLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6900
Mailing Address - Country:US
Mailing Address - Phone:520-749-4973
Mailing Address - Fax:
Practice Address - Street 1:5720 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3814
Practice Address - Country:US
Practice Address - Phone:520-747-8583
Practice Address - Fax:520-747-8561
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ520152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWCKGLMedicaid
AZ2477048OtherAETNA
AZ2Z4440OtherHEALTHNET
AZAZ0175250OtherBCBS
AZS5055OtherDME
AZ0188710001Medicare NSC
AZZ41WCKGL02Medicare PIN