Provider Demographics
NPI:1669975157
Name:KOKOPELLI EYE CARE PC
Entity type:Organization
Organization Name:KOKOPELLI EYE CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-775-5606
Mailing Address - Street 1:2820 N GLASSFORD HILL RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1242
Mailing Address - Country:US
Mailing Address - Phone:928-771-9000
Mailing Address - Fax:928-759-9902
Practice Address - Street 1:16605 E PALISADES BLVD STE 152
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3717
Practice Address - Country:US
Practice Address - Phone:844-565-6393
Practice Address - Fax:844-329-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26357332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030341Medicaid