Provider Demographics
NPI:1003991720
Name:MCCALLEN, ALICIA S (OD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:S
Last Name:MCCALLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:N
Other - Last Name:SOUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1444 S SOSSAMAN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3400
Mailing Address - Country:US
Mailing Address - Phone:480-333-6563
Mailing Address - Fax:
Practice Address - Street 1:1444 S SOSSAMAN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3400
Practice Address - Country:US
Practice Address - Phone:480-333-6563
Practice Address - Fax:480-333-6564
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist