Provider Demographics
NPI:1962480764
Name:MAYNARD, ROBERT JACK (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JACK
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W CAMELBACK RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2563
Mailing Address - Country:US
Mailing Address - Phone:602-264-4104
Mailing Address - Fax:602-241-0687
Practice Address - Street 1:114 W CAMELBACK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2563
Practice Address - Country:US
Practice Address - Phone:602-264-4104
Practice Address - Fax:602-241-0687
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0170990OtherBLUE CROSS BLUE SHIELD ID
AZ860292404OtherTAX ID
AZ860292404OtherTAX ID
AZ0543970001Medicare NSC