1902958135 NPI number — DR. MARK L. JAFFE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902958135 NPI number — DR. MARK L. JAFFE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MARK L. JAFFE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902958135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6666 W PEORIA AVE
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85302-7014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-979-8876
Provider Business Mailing Address Fax Number:
623-979-2811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6666 W PEORIA AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85302-7014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-979-8876
Provider Business Practice Location Address Fax Number:
623-979-2811
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JAFFE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
LAWRENCE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
623-979-8876

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  114 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114 . This is a "STATE OPTOMETRIC LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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