Healthcare Provider Details

I. General information

NPI: 1871502674
Provider Name (Legal Business Name): JAMES K CUNNINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E MAIN ST
ADA OK
74820-5614
US

IV. Provider business mailing address

700 E MAIN ST
ADA OK
74820-5614
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-3936
  • Fax: 580-332-3939
Mailing address:
  • Phone: 580-332-3936
  • Fax: 580-332-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOK-2031
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100761700A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: