Provider Demographics
NPI:1679539688
Name:NORTHERN ARIZONA EYE ASSOCIATES
Entity Type:Organization
Organization Name:NORTHERN ARIZONA EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-779-7000
Mailing Address - Street 1:PO BOX 31012
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-1012
Mailing Address - Country:US
Mailing Address - Phone:928-779-7000
Mailing Address - Fax:
Practice Address - Street 1:900 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3236
Practice Address - Country:US
Practice Address - Phone:928-779-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1Z0155OtherHEALTH NET
AZ490003130OtherMEDICARE RAILROAD
4533000OtherCIGNA
AZ383589Medicaid
AZ383589OtherAPIPA
AZAZ0204940OtherBLUE CROSS BLUE SHIELD
AZ383589Medicaid