Provider Demographics
NPI:1760458384
Name:SOBCHUK, TANIA NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:NICOLE
Last Name:SOBCHUK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1990 MCCULLOCH BLVD N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5749
Mailing Address - Country:US
Mailing Address - Phone:928-855-5026
Mailing Address - Fax:928-854-4512
Practice Address - Street 1:1990 MCCULLOCH BLVD N
Practice Address - Street 2:# 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5749
Practice Address - Country:US
Practice Address - Phone:928-855-5026
Practice Address - Fax:928-854-4512
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1311OtherSTATE LICENSE NUMBER
AZ806028Medicaid
MS0998419OtherDEA NUMBER
U96765Medicare UPIN
MS0998419OtherDEA NUMBER
AZ5398210001Medicare NSC