Healthcare Provider Details

I. General information

NPI: 1720426208
Provider Name (Legal Business Name): DR JOHN O SMITH OPTOMETRIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST
HENNESSEY OK
73742-1744
US

IV. Provider business mailing address

1201 S MAIN ST
HENNESSEY OK
73742-1744
US

V. Phone/Fax

Practice location:
  • Phone: 405-853-6800
  • Fax: 405-853-6805
Mailing address:
  • Phone: 405-853-6800
  • Fax: 405-853-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1014
License Number StateOK

VIII. Authorized Official

Name: DR. JOHN O. SMITH
Title or Position: PRESIDENT
Credential: O.D.
Phone: 405-853-6800