Provider Demographics
NPI:1023238755
Name:OKLAHOMA CITY VISION SOURCE
Entity type:Organization
Organization Name:OKLAHOMA CITY VISION SOURCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORESTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-840-2800
Mailing Address - Street 1:3011 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3629
Mailing Address - Country:US
Mailing Address - Phone:405-840-2800
Mailing Address - Fax:405-840-8242
Practice Address - Street 1:3011 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3629
Practice Address - Country:US
Practice Address - Phone:405-840-2800
Practice Address - Fax:405-840-8242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2464 TRENT PITT152W00000X
OK2099 SCOTT FORESTER152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763860AMedicaid
OK200062890AMedicaid
OKU43378Medicare UPIN
OKV07873Medicare UPIN
OK100763860AMedicaid
OK200062890AMedicaid
OK6229540001Medicare NSC