Provider Demographics
NPI:1659659498
Name:TATE, KYLE NICHOLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:NICHOLAS
Last Name:TATE
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 1:10010 E 81ST ST
Mailing Address - Street 2:STE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4556
Mailing Address - Country:US
Mailing Address - Phone:918-250-2020
Mailing Address - Fax:
Practice Address - Street 1:10010 E 81ST ST
Practice Address - Street 2:STE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4556
Practice Address - Country:US
Practice Address - Phone:918-250-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2715OtherSTATE OPTOMETRIC PHYSICIAN LICENSE