Healthcare Provider Details

I. General information

NPI: 1427556166
Provider Name (Legal Business Name): EYE CARE SPECIALISTS OF OKLAHOMA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 S BOULEVARD STE 105
EDMOND OK
73013
US

IV. Provider business mailing address

PO BOX 1803
EDMOND OK
73083-1803
US

V. Phone/Fax

Practice location:
  • Phone: 405-562-2036
  • Fax: 405-562-2116
Mailing address:
  • Phone: 405-418-4800
  • Fax: 405-418-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number29168
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JARED R JACKSON
Title or Position: PROVIDER
Credential: MD
Phone: 405-771-0880