Provider Demographics
NPI:1942059373
Name:POLLOCK, JUSTYN WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:JUSTYN
Middle Name:WILLIAM
Last Name:POLLOCK
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 1:955 W SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4903
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:
Practice Address - Street 1:5707 W NORTHERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1355
Practice Address - Country:US
Practice Address - Phone:602-512-3299
Practice Address - Fax:602-512-3303
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002794152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist