Provider Demographics
NPI:1982625703
Name:GUTHRIE VISION SOURCE PC, INC.
Entity Type:Organization
Organization Name:GUTHRIE VISION SOURCE PC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-282-4396
Mailing Address - Street 1:110 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-4839
Mailing Address - Country:US
Mailing Address - Phone:405-282-4396
Mailing Address - Fax:405-282-8298
Practice Address - Street 1:110 E HARRISON AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-4839
Practice Address - Country:US
Practice Address - Phone:405-282-4396
Practice Address - Fax:405-282-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDC6377OtherRR MEDICARE
OK100759960AMedicaid
OK100759960AMedicaid
OK400522401Medicare PIN