Provider Demographics
NPI:1396861654
Name:HERITAGE PARK EYE CARE CENTER
Entity Type:Organization
Organization Name:HERITAGE PARK EYE CARE CENTER
Other - Org Name:VISION SOURCE MIDWEST CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-732-2277
Mailing Address - Street 1:6912 E RENO AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2162
Mailing Address - Country:US
Mailing Address - Phone:405-732-2277
Mailing Address - Fax:405-737-4776
Practice Address - Street 1:6912 E RENO AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2162
Practice Address - Country:US
Practice Address - Phone:405-732-2277
Practice Address - Fax:405-737-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK758332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKCS4518OtherPALMETTO GROUP #
OKT40349Medicare UPIN