Provider Demographics
NPI:1083787535
Name:DRS. ODOM COBURN AND RICHARDSON
Entity Type:Organization
Organization Name:DRS. ODOM COBURN AND RICHARDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-682-7752
Mailing Address - Street 1:742 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-3866
Mailing Address - Country:US
Mailing Address - Phone:918-682-7752
Mailing Address - Fax:918-687-8440
Practice Address - Street 1:742 N YORK ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-3866
Practice Address - Country:US
Practice Address - Phone:918-682-7752
Practice Address - Fax:918-687-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
500522091Medicare PIN