Healthcare Provider Details

I. General information

NPI: 1730387846
Provider Name (Legal Business Name): JOHN B. MINNETT, O.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 W CHICKASHA AVE
CHICKASHA OK
73018-2413
US

IV. Provider business mailing address

619 W CHICKASHA AVE P.O. BOX 1599
CHICKASHA OK
73018-2413
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-5342
  • Fax: 405-222-2819
Mailing address:
  • Phone: 405-224-5342
  • Fax: 405-222-2819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2155
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2155
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2155
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2155
License Number StateOK

VIII. Authorized Official

Name: DR. CHRISTEN ROBERSON CLIFT
Title or Position: PRESIDENT/OWNER
Credential: O.D.
Phone: 405-224-5342