Provider Demographics
NPI:1538305982
Name:JEFFREY L. BURCHAM, OPTOMETRIST, INC.
Entity Type:Organization
Organization Name:JEFFREY L. BURCHAM, OPTOMETRIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-364-2020
Mailing Address - Street 1:444 24TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5110
Mailing Address - Country:US
Mailing Address - Phone:405-364-2020
Mailing Address - Fax:405-364-2021
Practice Address - Street 1:444 24TH AVE SW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5110
Practice Address - Country:US
Practice Address - Phone:405-364-2020
Practice Address - Fax:405-364-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152W00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763530Medicaid
OKOKB5339Medicare Oscar/Certification
OK0983760001Medicare NSC
OKT40377Medicare UPIN