Provider Demographics
NPI:1104914316
Name:TARA RANSDELL OD PLLC
Entity type:Organization
Organization Name:TARA RANSDELL OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANSDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:623-376-9070
Mailing Address - Street 1:21121 N 63RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6349
Mailing Address - Country:US
Mailing Address - Phone:623-328-7859
Mailing Address - Fax:623-376-9079
Practice Address - Street 1:7727 W DEER VALLEY RD
Practice Address - Street 2:STE E200
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2116
Practice Address - Country:US
Practice Address - Phone:623-376-9070
Practice Address - Fax:623-376-9079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDN9981Medicare PIN
AZZ183141Medicare PIN
AZZ114150Medicare PIN
AZU81050Medicare UPIN
AZZ114189Medicare PIN