Provider Demographics
NPI:1336586122
Name:DIVER, JOHN R (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DIVER
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 1:4606 E. 67TH ST
Mailing Address - Street 2:SUITE 400, BLDG. #7
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-949-9898
Mailing Address - Fax:918-728-8091
Practice Address - Street 1:4606 E. 67TH ST
Practice Address - Street 2:SUITE 400, BLDG. #7
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-949-9898
Practice Address - Fax:918-728-8091
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200498350AMedicaid