Provider Demographics
NPI:1376774406
Name:WOMACK, BRYAN L (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:L
Last Name:WOMACK
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 1:9424 N MAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2712
Mailing Address - Country:US
Mailing Address - Phone:405-751-8851
Mailing Address - Fax:405-751-5058
Practice Address - Street 1:9424 N MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2712
Practice Address - Country:US
Practice Address - Phone:405-751-8851
Practice Address - Fax:405-751-5058
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200270660AMedicaid
OK200270660AMedicaid
OKOK404220Medicare PIN