Provider Demographics
NPI:1043588791
Name:BUTCHER OPTICAL III, INC
Entity Type:Organization
Organization Name:BUTCHER OPTICAL III, INC
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-509-9245
Mailing Address - Street 1:13553 SR 54 # 311
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3527
Mailing Address - Country:US
Mailing Address - Phone:405-720-8316
Mailing Address - Fax:405-322-5758
Practice Address - Street 1:8549 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1521
Practice Address - Country:US
Practice Address - Phone:405-720-8316
Practice Address - Fax:405-720-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200110910AMedicaid
400522470Medicare PIN