Provider Demographics
NPI:1811518004
Name:TEJCHMA, COLLEEN ANNALINA (OD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANNALINA
Last Name:TEJCHMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 LAKE HAVASU AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-9368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:383 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-9368
Practice Address - Country:US
Practice Address - Phone:928-680-1144
Practice Address - Fax:928-680-8639
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002492152W00000X
390200000X
OK3100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program