Provider Demographics
NPI:1689621021
Name:MAHANEY, JAMES GIBSON (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GIBSON
Last Name:MAHANEY
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 1:119 N MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3621
Mailing Address - Country:US
Mailing Address - Phone:918-456-3552
Mailing Address - Fax:918-458-0402
Practice Address - Street 1:119 N MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3621
Practice Address - Country:US
Practice Address - Phone:918-456-3552
Practice Address - Fax:918-458-0402
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T40549Medicare UPIN
0159670001Medicare NSC