Provider Demographics
NPI:1912124751
Name:STILLWATER VISION CLINIC INC
Entity Type:Organization
Organization Name:STILLWATER VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUMM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-372-3724
Mailing Address - Street 1:2123 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4136
Mailing Address - Country:US
Mailing Address - Phone:405-372-3724
Mailing Address - Fax:405-743-1042
Practice Address - Street 1:2123 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4136
Practice Address - Country:US
Practice Address - Phone:405-372-3724
Practice Address - Fax:405-743-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK443721363001OtherDAVID REYNOLDS,OD BCBS
OK100768660BMedicaid
OK410033132OtherBRIAN GUMM,O.D. RR MCARE
OK448646516001OtherBRIAN GUMM,OD BCBS
OK100766180AMedicaid
OK410032462OtherDAVID REYNOLDS,OD RRMCARE
OK200005020AMedicaid
OK0210790001OtherSTILL VISION CL DMERC
OK100766010AMedicaid
OK410019936OtherJAMES STARK,O.D. RR MCARE
OK200005020AMedicaid
OK0210790001Medicare NSC
OK=========001OtherJAMES STARK,OD BCBSOK
OK0210790001OtherSTILL VISION CL DMERC
OK100766180AMedicaid
OK443721363Medicare ID - Type UnspecifiedDAVID REYNOLDS, O.D.
OKT40479Medicare UPIN
OK=========Medicare ID - Type UnspecifiedSTILLWATER VISION CLINIC
OK200005020AMedicaid