Provider Demographics
NPI:1336231653
Name:FORNARA, JOHN DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:FORNARA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:199 S CANDY LN
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4183
Mailing Address - Country:US
Mailing Address - Phone:928-634-2883
Mailing Address - Fax:928-634-0110
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:SUITE 2A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-634-2883
Practice Address - Fax:928-634-0110
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41609Medicare UPIN
AZZ124282Medicare PIN