Provider Demographics
NPI:1568957744
Name:EISLEY, COROM DUMAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:COROM
Middle Name:DUMAYNE
Last Name:EISLEY
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 1:2483 WINGFIELD HLS RD STE A100
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-7209
Mailing Address - Country:US
Mailing Address - Phone:775-446-7950
Mailing Address - Fax:775-441-9460
Practice Address - Street 1:2483 WINGFIELD HLS RD STE A100
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-7209
Practice Address - Country:US
Practice Address - Phone:775-446-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002262152W00000X
NV1011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1568957744Medicaid