Provider Demographics
NPI:1093060683
Name:BALOCCA, BRETT ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ALLEN
Last Name:BALOCCA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7071 N 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-2006
Mailing Address - Country:US
Mailing Address - Phone:623-516-4710
Mailing Address - Fax:
Practice Address - Street 1:18631 N 19TH AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5299
Practice Address - Country:US
Practice Address - Phone:623-516-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0002910152W00000X
AZ1921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162074Medicare PIN
AZZ162076Medicare PIN
AZZ163944Medicare PIN
AZZ163945Medicare PIN
AZZ163946Medicare PIN
AZZ162079Medicare PIN
AZZ162075Medicare PIN
AZZ162078Medicare PIN
AZZ162077Medicare PIN
AZZ163947Medicare PIN
AZZ163948Medicare PIN
AZZ163943Medicare PIN