Healthcare Provider Details

I. General information

NPI: 1700915956
Provider Name (Legal Business Name): SOUTHEASTERN OKLAHOMA EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W UNIVERSITY BLVD
DURANT OK
74701-3076
US

IV. Provider business mailing address

1901 W UNIVERSITY BLVD
DURANT OK
74701-3098
US

V. Phone/Fax

Practice location:
  • Phone: 580-920-2020
  • Fax: 580-924-5656
Mailing address:
  • Phone: 580-920-2020
  • Fax: 580-924-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: BARBARA OSTEEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 580-920-2020