Provider Demographics
NPI:1730321431
Name:LAVICKA, TAMMY (OD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:
Last Name:LAVICKA
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 1:6815 N 19TH AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1134
Mailing Address - Country:US
Mailing Address - Phone:602-242-5293
Mailing Address - Fax:
Practice Address - Street 1:6815 N 19TH AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1134
Practice Address - Country:US
Practice Address - Phone:602-242-5293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162074Medicare PIN
AZZ162076Medicare PIN
AZZ163384Medicare PIN