Provider Demographics
NPI:1205017779
Name:TONYA WARD JACKSON OD PC
Entity Type:Organization
Organization Name:TONYA WARD JACKSON OD PC
Other - Org Name:NEW VISION EYE AND LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-252-7432
Mailing Address - Street 1:8010 S 101ST EAST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4562
Mailing Address - Country:US
Mailing Address - Phone:918-252-7432
Mailing Address - Fax:918-250-9003
Practice Address - Street 1:8010 S 101ST EAST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4562
Practice Address - Country:US
Practice Address - Phone:918-252-7432
Practice Address - Fax:918-250-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100760900BMedicaid
OK0222050001Medicare PIN
OKU12319Medicare UPIN