Healthcare Provider Details

I. General information

NPI: 1720116932
Provider Name (Legal Business Name): ADVANTAGE EYECARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5335 W ROGERS BLVD STE B
SKIATOOK OK
74070-5284
US

IV. Provider business mailing address

5335 W ROGERS BLVD STE B
SKIATOOK OK
74070-5284
US

V. Phone/Fax

Practice location:
  • Phone: 918-396-4440
  • Fax: 918-396-4449
Mailing address:
  • Phone: 918-396-4440
  • Fax: 918-396-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2211
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2211
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2211
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2211
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code156FX1201X
TaxonomyOptometric Assistant Technician
License Number2211
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number2211
License Number StateOK

VIII. Authorized Official

Name: DR. SCOTT MICHAEL CARLSON
Title or Position: PRESIDENT
Credential: O.D.
Phone: 918-396-4440