Provider Demographics
NPI:1376749135
Name:OCOTILLO EYECARE P.C.
Entity Type:Organization
Organization Name:OCOTILLO EYECARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-812-3937
Mailing Address - Street 1:1674 W YELLOWSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4867
Mailing Address - Country:US
Mailing Address - Phone:480-786-6837
Mailing Address - Fax:
Practice Address - Street 1:3940 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4513
Practice Address - Country:US
Practice Address - Phone:480-812-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120468OtherMEDICARE PART B