Provider Demographics
NPI:1649238346
Name:CHAMP, AMY H (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:H
Last Name:CHAMP
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 1:3192 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6610
Mailing Address - Country:US
Mailing Address - Phone:928-778-3950
Mailing Address - Fax:
Practice Address - Street 1:3192 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6610
Practice Address - Country:US
Practice Address - Phone:928-778-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ437732Medicaid
AZ437732Medicaid
AZZ109530Medicare PIN