Provider Demographics
NPI:1538440367
Name:PHOENIX EYE INSTITUTE PLLC
Entity type:Organization
Organization Name:PHOENIX EYE INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIN
Authorized Official - Middle Name:CHEOL
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:623-773-3937
Mailing Address - Street 1:PO BOX 5609
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385-5609
Mailing Address - Country:US
Mailing Address - Phone:623-773-3937
Mailing Address - Fax:623-773-3955
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5639
Practice Address - Country:US
Practice Address - Phone:623-773-3937
Practice Address - Fax:623-773-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36025207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ150092Medicare PIN