Provider Demographics
NPI:1821457532
Name:OCULOPLASTIC EYE SURGEONS OF PHOENIX P.L.C.
Entity Type:Organization
Organization Name:OCULOPLASTIC EYE SURGEONS OF PHOENIX P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:MIHORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-788-1134
Mailing Address - Street 1:9151 W THUNDERBIRD RD # G104
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4906
Mailing Address - Country:US
Mailing Address - Phone:480-788-1134
Mailing Address - Fax:623-522-8683
Practice Address - Street 1:9151 W THUNDERBIRD RD # G104
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4906
Practice Address - Country:US
Practice Address - Phone:623-522-8687
Practice Address - Fax:623-522-8683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44635207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ143418Medicaid