Provider Demographics
NPI:1760749659
Name:PROFESSIONAL OPTOMETRIC SERVICES, PC
Entity Type:Organization
Organization Name:PROFESSIONAL OPTOMETRIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-939-1213
Mailing Address - Street 1:19190 S ALPHA AVE
Mailing Address - Street 2:APT. 9205
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-4846
Mailing Address - Country:US
Mailing Address - Phone:248-939-1213
Mailing Address - Fax:856-219-8259
Practice Address - Street 1:3501 E BROADWAY BLVD
Practice Address - Street 2:OPTICAL DEPT
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5405
Practice Address - Country:US
Practice Address - Phone:520-241-9522
Practice Address - Fax:520-881-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285719237OtherNPI TYPE 1
AZ691957Medicaid
MI2468OtherEYEMED
1285719237OtherNPI TYPE 1
MI2468OtherEYEMED