Provider Demographics
NPI:1639233612
Name:POAGE EYECARE, PC
Entity Type:Organization
Organization Name:POAGE EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:POAGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-256-0126
Mailing Address - Street 1:1432 N MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7214
Mailing Address - Country:US
Mailing Address - Phone:405-256-0126
Mailing Address - Fax:405-256-0563
Practice Address - Street 1:1432 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7214
Practice Address - Country:US
Practice Address - Phone:405-256-0126
Practice Address - Fax:405-256-0563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2430152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20006384830AMedicaid
OKOKB5562Medicare PIN
OK400522446Medicare ID - Type Unspecified