Provider Demographics
NPI:1568675452
Name:KEATHLEY, BOB R
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:R
Last Name:KEATHLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 SOUTH SHERIDAN
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145
Mailing Address - Country:US
Mailing Address - Phone:918-494-2671
Mailing Address - Fax:918-496-1993
Practice Address - Street 1:6025 SOUTH SHERIDAN
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145
Practice Address - Country:US
Practice Address - Phone:918-494-2671
Practice Address - Fax:918-496-1993
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK020779156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0727760001Medicare ID - Type Unspecified