Healthcare Provider Details

I. General information

NPI: 1427490994
Provider Name (Legal Business Name): RICHARD BRANDON RUNYON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 07/24/2013
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

153 SOUTHRIDGE RD APT. 2
TAHLEQUAH OK
74464-5688
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-4000
  • Fax:
Mailing address:
  • Phone: 606-424-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2792
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: