Provider Demographics
NPI:1568017408
Name:VISTA EYECARE
Entity Type:Organization
Organization Name:VISTA EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-270-4410
Mailing Address - Street 1:9720 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-1206
Mailing Address - Country:US
Mailing Address - Phone:918-270-4410
Mailing Address - Fax:
Practice Address - Street 1:9720 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-1206
Practice Address - Country:US
Practice Address - Phone:918-270-4410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1205314572Medicaid