Provider Demographics
NPI:1659460848
Name:SCHROLUCKE, JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:SCHROLUCKE
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 1:5140 W PEORIA AVE
Mailing Address - Street 2:STE. 116
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-1630
Mailing Address - Country:US
Mailing Address - Phone:623-487-1100
Mailing Address - Fax:623-487-1417
Practice Address - Street 1:5140 W PEORIA AVE
Practice Address - Street 2:STE. 116
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-1630
Practice Address - Country:US
Practice Address - Phone:623-487-1100
Practice Address - Fax:623-487-1417
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZOD212Medicare PIN
AZZ$$$$$$$$$Medicare PIN