Healthcare Provider Details

I. General information

NPI: 1154356590
Provider Name (Legal Business Name): WILLIAM LEE EVANS III OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WILLIAM LEE EVANS III OD

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EAST 2ND ST
ATOKA OK
74525-0000
US

IV. Provider business mailing address

PO BOX 396 100 EAST 2ND ST
ATOKA OK
74525
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-3492
  • Fax: 580-889-3499
Mailing address:
  • Phone: 580-889-3492
  • Fax: 580-889-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOK959
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: