Provider Demographics
NPI:1114062668
Name:COOLEY STALEY, TINA (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:COOLEY STALEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 E BOSTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6246
Mailing Address - Country:US
Mailing Address - Phone:480-813-7050
Mailing Address - Fax:480-813-3630
Practice Address - Street 1:1780 E BOSTON ST
Practice Address - Street 2:STE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6244
Practice Address - Country:US
Practice Address - Phone:480-813-7050
Practice Address - Fax:480-813-3630
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U45313Medicare UPIN