Provider Demographics
NPI:1386857811
Name:GUYMON VISION CLINIC
Entity Type:Organization
Organization Name:GUYMON VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MACK
Authorized Official - Middle Name:WRAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-338-8437
Mailing Address - Street 1:301 NORTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-2735
Mailing Address - Country:US
Mailing Address - Phone:580-338-8437
Mailing Address - Fax:580-338-8361
Practice Address - Street 1:301 NORTHRIDGE CIR
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-2735
Practice Address - Country:US
Practice Address - Phone:580-338-8437
Practice Address - Fax:580-338-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0313740001Medicare Oscar/Certification
OK0313740001Medicare PIN
OK0313740001Medicare UPIN
OK0313740001Medicare NSC