Provider Demographics
NPI:1720116932
Name:ADVANTAGE EYECARE, P.C.
Entity Type:Organization
Organization Name:ADVANTAGE EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-396-4440
Mailing Address - Street 1:5335 W ROGERS BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-5284
Mailing Address - Country:US
Mailing Address - Phone:918-396-4440
Mailing Address - Fax:918-396-4449
Practice Address - Street 1:5335 W ROGERS BLVD
Practice Address - Street 2:STE B
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-5284
Practice Address - Country:US
Practice Address - Phone:918-396-4440
Practice Address - Fax:918-396-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2211152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 156FX1201X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100747330AMedicaid
OK100747330AMedicaid
OKU67453Medicare UPIN
OK1227920001Medicare NSC
OKOKB5376Medicare PIN