Healthcare Provider Details

I. General information

NPI: 1033388962
Provider Name (Legal Business Name): MID TOWN OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W GRAY ST STE 130
NORMAN OK
73069-7111
US

IV. Provider business mailing address

330 W GRAY ST STE 130
NORMAN OK
73069-7111
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN JOHNSON
Title or Position: OWNER/OPTICAN
Credential:
Phone: 405-360-5505