Provider Demographics
NPI:1003970757
Name:ADVANCED LASER & EYE CENTER OF AZ PC
Entity Type:Organization
Organization Name:ADVANCED LASER & EYE CENTER OF AZ PC
Other - Org Name:ALECA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIANOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-632-2020
Mailing Address - Street 1:3303 E BASELINE RD
Mailing Address - Street 2:#104
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2739
Mailing Address - Country:US
Mailing Address - Phone:480-632-2020
Mailing Address - Fax:480-632-2121
Practice Address - Street 1:4920 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-5547
Practice Address - Country:US
Practice Address - Phone:480-632-2020
Practice Address - Fax:480-632-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22618207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0805550OtherBCBS
AZ172809Medicaid
AZZ72934Medicare PIN
AZAZ0805550OtherBCBS
AZ172809Medicaid