Provider Demographics
NPI:1225257249
Name:MARK B. PRIVOTT, O.D., INC
Entity Type:Organization
Organization Name:MARK B. PRIVOTT, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:PRIVOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-495-5170
Mailing Address - Street 1:7415 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5135
Mailing Address - Country:US
Mailing Address - Phone:405-495-5170
Mailing Address - Fax:405-787-0123
Practice Address - Street 1:7415 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5135
Practice Address - Country:US
Practice Address - Phone:405-495-5170
Practice Address - Fax:405-787-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40609Medicare UPIN
1186900001Medicare NSC