Basic Information
| Provider Information | |||||||||
| NPI: | 1780641910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUG | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | OD | ||||||||
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| OtherLastName: | HUG | ||||||||
| OtherFirstName: | TIM | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 S HIGLEY RD STE 106 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029333937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-002422 | AZ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | TO2937 | MO | N | Eye and Vision Services Providers | Optometrist | 152WP0200X | OPT-002422 | AZ | Y | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 080431 | 05 | AZ | MEDICAID |