Provider Demographics
NPI:1093717373
Name:JAFFE, MARK LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:JAFFE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6404 W WETHERSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1630
Mailing Address - Country:US
Mailing Address - Phone:623-878-8538
Mailing Address - Fax:623-878-8538
Practice Address - Street 1:6666 W PEORIA AVE
Practice Address - Street 2:STE 109
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-7032
Practice Address - Country:US
Practice Address - Phone:623-979-8876
Practice Address - Fax:623-979-2811
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00360908OtherRAIL ROAD MEDICARE
AZT41774Medicare UPIN