Provider Demographics
NPI:1447690607
Name:KITZEROW, ALISON DOMENICA (OD)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:DOMENICA
Last Name:KITZEROW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:4800 N 22ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4701
Practice Address - Country:US
Practice Address - Phone:602-955-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ 2038152W00000X
GAOPT002755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002755OtherGA OPTOMETRY LICENSE
AZ2038OtherAZ MEDICAL LICENSE