Provider Demographics
NPI:1295852861
Name:NORTHWEST OPTICAL INC.
Entity Type:Organization
Organization Name:NORTHWEST OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:KORBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-946-9830
Mailing Address - Street 1:5320 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2098
Mailing Address - Country:US
Mailing Address - Phone:405-946-9830
Mailing Address - Fax:405-947-3494
Practice Address - Street 1:5320 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2098
Practice Address - Country:US
Practice Address - Phone:405-947-3330
Practice Address - Fax:405-947-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20179332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4129560001Medicare NSC