Provider Demographics
NPI:1295873453
Name:VERNON, PAUL H (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
Last Name:VERNON
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 1:7030 N 11TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5313
Mailing Address - Country:US
Mailing Address - Phone:602-870-4762
Mailing Address - Fax:
Practice Address - Street 1:2900 S PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-3500
Practice Address - Country:US
Practice Address - Phone:928-314-0103
Practice Address - Fax:928-314-0119
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13386066AMedicare ID - Type Unspecified
AZT78910Medicare UPIN