Healthcare Provider Details

I. General information

NPI: 1275501033
Provider Name (Legal Business Name): ANN L. MCIVER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W MAIN ST
MARIETTA OK
73448-2847
US

IV. Provider business mailing address

PO BOX 267
MARIETTA OK
73448-0267
US

V. Phone/Fax

Practice location:
  • Phone: 580-276-5548
  • Fax: 580-276-5541
Mailing address:
  • Phone: 580-276-5548
  • Fax: 580-276-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2139
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: