Provider Demographics
NPI:1245210020
Name:POAGE, REBECCA LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:POAGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 N MUSTANG RD STE A
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7214
Mailing Address - Country:US
Mailing Address - Phone:405-256-0126
Mailing Address - Fax:405-256-0563
Practice Address - Street 1:500 N FINANCIAL TER
Practice Address - Street 2:SUITE A
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4432
Practice Address - Country:US
Practice Address - Phone:405-256-0126
Practice Address - Fax:405-256-0563
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2430152WC0802X, 152WL0500X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064830AMedicaid
OKOKB5562OtherMEDICARE GROUP PTAN
OK200063870AMedicaid
OKOKB5562OtherMEDICARE GROUP PTAN
OKV04580Medicare UPIN