Provider Demographics
NPI:1730359688
Name:ALLAN M. ANHALT
Entity type:Organization
Organization Name:ALLAN M. ANHALT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ANHALT
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:602-258-3620
Mailing Address - Street 1:333 E VIRGINIA AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1206
Mailing Address - Country:US
Mailing Address - Phone:602-258-3620
Mailing Address - Fax:602-258-1593
Practice Address - Street 1:2122 N CRAYCROFT RD
Practice Address - Street 2:SUITE 118
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2849
Practice Address - Country:US
Practice Address - Phone:520-325-3121
Practice Address - Fax:602-258-1593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ351487Medicaid
AZ351487Medicaid