Healthcare Provider Details

I. General information

NPI: 1578907598
Provider Name (Legal Business Name): MID-DEL VISION SOURCE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2013
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 SE 15TH ST SUITE A
DEL CITY OK
73115-3952
US

IV. Provider business mailing address

5113 SE 15TH ST SUITE A
DEL CITY OK
73115-3952
US

V. Phone/Fax

Practice location:
  • Phone: 405-677-8831
  • Fax:
Mailing address:
  • Phone: 405-677-8831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE STRICKLIN
Title or Position: ASSISTANT DIRECTOR OF OPERATIONS
Credential:
Phone: 405-732-2277