Provider Demographics
NPI:1235215393
Name:MACE, JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 S. MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6703
Mailing Address - Country:US
Mailing Address - Phone:405-324-0001
Mailing Address - Fax:405-324-0015
Practice Address - Street 1:ULTIMATE VISION
Practice Address - Street 2:334 S. MUSTANG RD
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6703
Practice Address - Country:US
Practice Address - Phone:405-324-0001
Practice Address - Fax:405-324-0015
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2004380027309OtherTRICARE
OK2004380027309OtherTRICARE
5323620001Medicare NSC
OKU84128Medicare UPIN