Provider Demographics
NPI:1730259227
Name:FORD, TROY SLADE (OD)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:SLADE
Last Name:FORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S BEELINE HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4892
Mailing Address - Country:US
Mailing Address - Phone:928-474-3556
Mailing Address - Fax:928-474-3161
Practice Address - Street 1:411 S BEELINE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4892
Practice Address - Country:US
Practice Address - Phone:928-474-3556
Practice Address - Fax:928-474-3161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOD790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ101254-01Medicaid
AZ1275722498OtherDMERC
AZ70475Medicare ID - Type Unspecified
AZ1275722498Medicare NSC
AZU20702Medicare UPIN