Provider Demographics
NPI:1013256486
Name:ENVISION MEDICAL & SURGICAL EYE CARE PC
Entity Type:Organization
Organization Name:ENVISION MEDICAL & SURGICAL EYE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:RENFROW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-605-7456
Mailing Address - Street 1:4926 W KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8517
Mailing Address - Country:US
Mailing Address - Phone:918-605-7456
Mailing Address - Fax:918-893-1724
Practice Address - Street 1:4926 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8517
Practice Address - Country:US
Practice Address - Phone:918-605-7456
Practice Address - Fax:918-893-1724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENVISION MEDICAL AND SURGICAL EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-05
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4949207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA102502OtherMEDICARE PTAN