Healthcare Provider Details

I. General information

NPI: 1063865624
Provider Name (Legal Business Name): RIYAD KHAMIS O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

IV. Provider business mailing address

1512 N KENNEDY LN
TAHLEQUAH OK
74464-4454
US

V. Phone/Fax

Practice location:
  • Phone: 918-822-1299
  • Fax:
Mailing address:
  • Phone: 918-822-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2890
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: