Provider Demographics
NPI:1699818864
Name:SOUTHERN OKLAHOMA EYE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA EYE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-665-5685
Mailing Address - Street 1:212 S DEAN A MCGEE AVE
Mailing Address - Street 2:PO BOX 519
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-7810
Mailing Address - Country:US
Mailing Address - Phone:405-665-5685
Mailing Address - Fax:405-665-5694
Practice Address - Street 1:212 S DEAN A MCGEE AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-7810
Practice Address - Country:US
Practice Address - Phone:405-665-5685
Practice Address - Fax:405-665-5694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0418650002Medicare NSC