Provider Demographics
NPI:1003997305
Name:RILEY, JOHN ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:RILEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:530 E HUNT HWY
Mailing Address - Street 2:STE 103
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-6582
Mailing Address - Country:US
Mailing Address - Phone:520-251-3688
Mailing Address - Fax:480-281-0206
Practice Address - Street 1:3931 S GILBERT RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-2004
Practice Address - Country:US
Practice Address - Phone:480-281-0204
Practice Address - Fax:480-281-0206
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79928Medicare ID - Type UnspecifiedPROVIDER ID NUMBER
AZU90500Medicare UPIN
AZ79926Medicare PIN