Provider Demographics
NPI:1154441848
Name:BROADWAY VISION ASSOCIATES, PLC
Entity Type:Organization
Organization Name:BROADWAY VISION ASSOCIATES, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-687-4459
Mailing Address - Street 1:435 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6614
Mailing Address - Country:US
Mailing Address - Phone:918-687-4459
Mailing Address - Fax:918-687-0238
Practice Address - Street 1:435 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6614
Practice Address - Country:US
Practice Address - Phone:918-687-4459
Practice Address - Fax:918-687-0238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739020AMedicaid
OK6260680001Medicare NSC
OK300522029Medicare PIN