Provider Demographics
NPI:1710043708
Name:WALT P. MEGOWN OD INC.
Entity Type:Organization
Organization Name:WALT P. MEGOWN OD INC.
Other - Org Name:OKMULGEE VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALT
Authorized Official - Middle Name:P
Authorized Official - Last Name:MEGOWN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-756-2124
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-0610
Mailing Address - Country:US
Mailing Address - Phone:918-756-2124
Mailing Address - Fax:918-756-3865
Practice Address - Street 1:916 E 8TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4724
Practice Address - Country:US
Practice Address - Phone:918-756-2124
Practice Address - Fax:918-756-3865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK880152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100730920BMedicaid
730950703001OtherBCBS
OK100730920BMedicaid
OK1132420001Medicare NSC