Provider Demographics
NPI:1265689129
Name:CRAIG, KYLE E (OD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:E
Last Name:CRAIG
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 1:1701 S PEORIA AVE
Mailing Address - Street 2:200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-6801
Mailing Address - Country:US
Mailing Address - Phone:918-599-0202
Mailing Address - Fax:918-599-0279
Practice Address - Street 1:1701 S PEORIA AVE
Practice Address - Street 2:200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-6801
Practice Address - Country:US
Practice Address - Phone:918-599-0202
Practice Address - Fax:918-599-0279
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200209770AMedicaid
OKOK401275Medicare PIN
OK200209770AMedicaid