Healthcare Provider Details

I. General information

NPI: 1457447062
Provider Name (Legal Business Name): JOHN D HUDKINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4008 S ELM PL SUITE A
BROKEN ARROW OK
74011-2021
US

IV. Provider business mailing address

4008 S ELM PL SUITE A
BROKEN ARROW OK
74011-2021
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-2020
  • Fax: 918-455-4030
Mailing address:
  • Phone: 918-455-2020
  • Fax: 918-455-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number909
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number909
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number909
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number909
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number909
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number909
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: