Provider Demographics
NPI:1164557625
Name:TULSA VISION CLINIC, INC.
Entity Type:Organization
Organization Name:TULSA VISION CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-743-6334
Mailing Address - Street 1:4433 SOUTH HARVARD AVE.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2604
Mailing Address - Country:US
Mailing Address - Phone:918-743-6334
Mailing Address - Fax:918-743-6369
Practice Address - Street 1:4433 SOUTH HARVARD AVE.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2604
Practice Address - Country:US
Practice Address - Phone:918-743-6334
Practice Address - Fax:918-743-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2356332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109710AMedicaid
OK200109710AMedicaid
OK200109710AMedicaid
OK=========OtherTAX ID NUMBER