Provider Demographics
NPI:1558470583
Name:CZYZ, THOMAS R (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:CZYZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42201 N 41ST DR
Mailing Address - Street 2:SUITE 144
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3800
Mailing Address - Country:US
Mailing Address - Phone:623-551-9122
Mailing Address - Fax:623-551-9120
Practice Address - Street 1:42201 N 41ST DR
Practice Address - Street 2:SUITE 124-128
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3800
Practice Address - Country:US
Practice Address - Phone:623-551-9122
Practice Address - Fax:623-551-9120
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1146152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0903340OtherBLUE CROSS BLUE SHIELD
AZU89382Medicare UPIN
AZZ68452Medicare ID - Type UnspecifiedMEDICARE