Provider Demographics
NPI:1437221124
Name:BRESHEARS, JUDY (OD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:BRESHEARS
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 1:16013 E GLENDORA DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 N GILBERT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-7551
Practice Address - Country:US
Practice Address - Phone:480-827-9184
Practice Address - Fax:480-461-0703
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ885152W00000X
OK1101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDB1051OtherRAILROAD MEDICARE GROUP ID
AZP00112635OtherRAILROAD MEDICARE PIN
AZP00112635OtherRAILROAD MEDICARE PIN
AZT40369Medicare UPIN