Provider Demographics
NPI:1962442848
Name:YANDELL, BURNESS R (OD)
Entity Type:Individual
Prefix:
First Name:BURNESS
Middle Name:R
Last Name:YANDELL
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:P.O. BOX 452529
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-2529
Mailing Address - Country:US
Mailing Address - Phone:918-786-9777
Mailing Address - Fax:918-786-3345
Practice Address - Street 1:1013 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2847
Practice Address - Country:US
Practice Address - Phone:918-786-9777
Practice Address - Fax:918-786-3345
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1962442848OtherADVANTRA FREEDOM
OK110763110AMedicaid
731086218001OtherBCBS
T40728Medicare UPIN
0445410001Medicare NSC
410010874Medicare PIN
1962442848Medicare PIN