Provider Demographics
NPI:1568599496
Name:MARK A. MANAHAN, O.D., INC
Entity Type:Organization
Organization Name:MARK A. MANAHAN, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ARLEN
Authorized Official - Last Name:MANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-245-2020
Mailing Address - Street 1:305 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7910
Mailing Address - Country:US
Mailing Address - Phone:918-245-2020
Mailing Address - Fax:918-245-2010
Practice Address - Street 1:305 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7910
Practice Address - Country:US
Practice Address - Phone:918-245-2020
Practice Address - Fax:918-245-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK962152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK410020609OtherRAILROAD MEDICARE
OK100765990AMedicaid
OK410020609OtherRAILROAD MEDICARE
OK100765990AMedicaid
OK6463730001Medicare NSC