Healthcare Provider Details

I. General information

NPI: 1639233612
Provider Name (Legal Business Name): POAGE EYECARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 N MUSTANG RD
MUSTANG OK
73064-7214
US

IV. Provider business mailing address

1432 N MUSTANG RD
MUSTANG OK
73064-7214
US

V. Phone/Fax

Practice location:
  • Phone: 405-256-0126
  • Fax: 405-256-0563
Mailing address:
  • Phone: 405-256-0126
  • Fax: 405-256-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2430
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2430
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2430
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2430
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2430
License Number StateOK

VIII. Authorized Official

Name: DR. REBECCA LYNN POAGE
Title or Position: OWNER
Credential: OD
Phone: 405-256-0126