Provider Demographics
NPI: | 1619039518 |
---|---|
Name: | MEGOWN, WALTER PRESLEY (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | WALTER |
Middle Name: | PRESLEY |
Last Name: | MEGOWN |
Suffix: | |
Gender: | M |
Credentials: | OD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 610 |
Mailing Address - Street 2: | |
Mailing Address - City: | OKMULGEE |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74447-0610 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 918-756-2124 |
Mailing Address - Fax: | 918-756-3865 |
Practice Address - Street 1: | 916 E 8TH ST |
Practice Address - Street 2: | |
Practice Address - City: | OKMULGEE |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74447-4724 |
Practice Address - Country: | US |
Practice Address - Phone: | 918-756-2124 |
Practice Address - Fax: | 918-756-3865 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-12-15 |
Last Update Date: | 2013-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | OK880 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OK | 410038339 | Other | RAILROAD MEDICARE PTAN |
OK | 100761970A | Medicaid | |
730950703001 | Other | BC/BS | |
OK | 410038339 | Other | RAILROAD MEDICARE PTAN |
730950703001 | Other | BC/BS | |
T40561 | Medicare UPIN | ||
OK | 100761970A | Medicaid |