Provider Demographics
NPI:1790256626
Name:LAD, DAXA (OD)
Entity Type:Individual
Prefix:DR
First Name:DAXA
Middle Name:
Last Name:LAD
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 1:17339 E EL PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-2634
Mailing Address - Country:US
Mailing Address - Phone:615-972-0774
Mailing Address - Fax:
Practice Address - Street 1:9055 E TALKING STICK WAY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-8521
Practice Address - Country:US
Practice Address - Phone:480-948-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist