Provider Demographics
NPI:1144328485
Name:DESERT OPHTHALMOLOGY, P.C.
Entity type:Organization
Organization Name:DESERT OPHTHALMOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GUSTASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-425-5203
Mailing Address - Street 1:9615 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2319
Mailing Address - Country:US
Mailing Address - Phone:928-425-5203
Mailing Address - Fax:928-425-5620
Practice Address - Street 1:5860 S HOSPITAL DR STE 101
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9449
Practice Address - Country:US
Practice Address - Phone:928-425-5203
Practice Address - Fax:928-425-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5469207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5469Medicare ID - Type Unspecified
AZC99602Medicare UPIN