Provider Demographics
NPI:1477560019
Name:MAYER, TATYANA VICTORIA (OD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:VICTORIA
Last Name:MAYER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 N 4TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2745
Mailing Address - Country:US
Mailing Address - Phone:580-762-0870
Mailing Address - Fax:580-762-0871
Practice Address - Street 1:1722 N 4TH ST STE C
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2745
Practice Address - Country:US
Practice Address - Phone:580-762-0870
Practice Address - Fax:580-762-0871
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5478300001Medicare NSC