Provider Demographics
NPI:1093711939
Name:MACH, BRIAN A (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:MACH
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:PO BOX 16996
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6996
Mailing Address - Country:US
Mailing Address - Phone:602-424-0866
Mailing Address - Fax:602-424-0865
Practice Address - Street 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:#H-3
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-424-0866
Practice Address - Fax:602-424-0865
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035073Medicaid
AZ73633Medicare PIN
T76712Medicare UPIN