Provider Demographics
NPI:1811186976
Name:STACEY MURRELL, OD PC INC
Entity Type:Organization
Organization Name:STACEY MURRELL, OD PC INC
Other - Org Name:BROKEN ARROW VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDEN
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-258-9999
Mailing Address - Street 1:1406 S ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4807
Mailing Address - Country:US
Mailing Address - Phone:918-258-9999
Mailing Address - Fax:918-258-2850
Practice Address - Street 1:1406 S ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4807
Practice Address - Country:US
Practice Address - Phone:918-258-9999
Practice Address - Fax:918-258-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762280AMedicaid
OK100762280AMedicaid
OKU86575Medicare UPIN