Healthcare Provider Details

I. General information

NPI: 1538151337
Provider Name (Legal Business Name): LANCE L. LEDBETTER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 W MAIN ST
MOORE OK
73160-5142
US

IV. Provider business mailing address

232 W MAIN ST
MOORE OK
73160-5142
US

V. Phone/Fax

Practice location:
  • Phone: 405-794-3588
  • Fax: 405-794-0306
Mailing address:
  • Phone: 405-794-3588
  • Fax: 405-794-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1180
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: