Provider Demographics
NPI:1649588419
Name:ENVISION MEDICAL & SURGICAL EYE CARE, PC
Entity Type:Organization
Organization Name:ENVISION MEDICAL & SURGICAL EYE CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENFROW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-421-6656
Mailing Address - Street 1:4 E CLARK BASS BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4269
Mailing Address - Country:US
Mailing Address - Phone:918-421-6656
Mailing Address - Fax:918-421-6659
Practice Address - Street 1:4 E CLARK BASS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4269
Practice Address - Country:US
Practice Address - Phone:918-421-6656
Practice Address - Fax:918-421-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4949207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty