Provider Demographics
NPI:1396884813
Name:HARRISON, WAYMON DALE (OD)
Entity type:Individual
Prefix:DR
First Name:WAYMON
Middle Name:DALE
Last Name:HARRISON
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 1:11653 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5801
Mailing Address - Country:US
Mailing Address - Phone:405-691-2210
Mailing Address - Fax:405-691-0136
Practice Address - Street 1:11653 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5801
Practice Address - Country:US
Practice Address - Phone:405-691-2210
Practice Address - Fax:405-691-0136
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU37724Medicare UPIN
OKOKA104122Medicare PIN