Healthcare Provider Details

I. General information

NPI: 1154441848
Provider Name (Legal Business Name): BROADWAY VISION ASSOCIATES, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W BROADWAY ST
MUSKOGEE OK
74401-6614
US

IV. Provider business mailing address

435 W BROADWAY ST
MUSKOGEE OK
74401-6614
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-4459
  • Fax: 918-687-0238
Mailing address:
  • Phone: 918-687-4459
  • Fax: 918-687-0238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CANDACE Y. STEWART
Title or Position: OD OWNER
Credential: OD
Phone: 918-687-4459