Provider Demographics
NPI:1245284934
Name:ADVANCED LASER &EYE CENTER OF ARIZONA PC
Entity type:Organization
Organization Name:ADVANCED LASER &EYE CENTER OF ARIZONA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIANOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-632-2020
Mailing Address - Street 1:3303 E BASELINE RD
Mailing Address - Street 2:#104
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2739
Mailing Address - Country:US
Mailing Address - Phone:480-632-2020
Mailing Address - Fax:480-632-2121
Practice Address - Street 1:3303 E BASELINE RD
Practice Address - Street 2:#104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2739
Practice Address - Country:US
Practice Address - Phone:480-632-2020
Practice Address - Fax:480-632-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22618207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1009192OtherAETNA INS CO
33209OtherEVERCARE
AZ3Z3345OtherHEALTHNET
33209OtherEVERCARE
AZP00353617Medicare PIN
AZ1319220002Medicare NSC