Provider Demographics
NPI:1962499434
Name:BLANK, ROBIN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:
Last Name:BLANK
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 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:7650 W BELL RD # 3
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8619
Practice Address - Country:US
Practice Address - Phone:623-412-2020
Practice Address - Fax:623-825-7369
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ24852Medicare PIN
AZU72759Medicare UPIN