Provider Demographics
NPI:1629089594
Name:JOHNSON OPTICAL DISPENSARY
Entity Type:Organization
Organization Name:JOHNSON OPTICAL DISPENSARY
Other - Org Name:OKLAHOMA EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-426-5922
Mailing Address - Street 1:602 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5822
Mailing Address - Country:US
Mailing Address - Phone:918-426-5922
Mailing Address - Fax:918-423-2115
Practice Address - Street 1:602 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5822
Practice Address - Country:US
Practice Address - Phone:918-426-5922
Practice Address - Fax:918-423-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK933332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK261QM2500XOtherTAXONOMY
OK100768860BMedicaid
OK261QM2500XOtherTAXONOMY
OK=========002OtherBLUECROSS/BLUE SHIELD
OK=========002OtherCIGNA
OK261QM2500XOtherTAXONOMY
OK200522083Medicare ID - Type Unspecified