Provider Demographics
NPI:1205172251
Name:DIAMOND PEAK VISION, PLLC
Entity type:Organization
Organization Name:DIAMOND PEAK VISION, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMORDAUNT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:925-222-1957
Mailing Address - Street 1:524 S BARKLEY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2707
Mailing Address - Country:US
Mailing Address - Phone:925-222-1957
Mailing Address - Fax:623-872-0947
Practice Address - Street 1:5010 N 95TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3042
Practice Address - Country:US
Practice Address - Phone:623-872-0945
Practice Address - Fax:623-872-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty