Provider Demographics
NPI:1548245293
Name:DESERT EYE PC
Entity Type:Organization
Organization Name:DESERT EYE PC
Other - Org Name:DESERT FAMILY EYE CARE PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DUGAN
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-966-0522
Mailing Address - Street 1:3200 S RURAL RD
Mailing Address - Street 2:#1
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:480-966-0522
Mailing Address - Fax:480-966-0650
Practice Address - Street 1:3200 S RURAL RD
Practice Address - Street 2:#1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-966-0522
Practice Address - Fax:480-966-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ49142301Medicaid
AZZ147459OtherPTAN
AZZ147459OtherPTAN
AZ49142301Medicaid