Provider Demographics
NPI:1942561691
Name:VISION AND EYE MEDICAL DIAGNOSTIC LASER CENTER
Entity Type:Organization
Organization Name:VISION AND EYE MEDICAL DIAGNOSTIC LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-266-3411
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-0098
Mailing Address - Country:US
Mailing Address - Phone:918-266-3411
Mailing Address - Fax:918-266-3412
Practice Address - Street 1:2310 N HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3070
Practice Address - Country:US
Practice Address - Phone:918-266-3411
Practice Address - Fax:918-266-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40428Medicare UPIN