Provider Demographics
NPI:1588831556
Name:ASSOCIATED OPTOMETRIST OF OKLAHOMA - SOUTH, P.C.
Entity Type:Organization
Organization Name:ASSOCIATED OPTOMETRIST OF OKLAHOMA - SOUTH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARAOPTOMETRIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX-MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-691-3937
Mailing Address - Street 1:10320 S PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6916
Mailing Address - Country:US
Mailing Address - Phone:405-691-3937
Mailing Address - Fax:405-691-0312
Practice Address - Street 1:10320 S PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6916
Practice Address - Country:US
Practice Address - Phone:405-691-3937
Practice Address - Fax:405-691-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK978152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764890AMedicaid
OK100764890AMedicaid
OKOKA101624Medicare PIN
OK4763870001Medicare NSC