Healthcare Provider Details

I. General information

NPI: 1457757429
Provider Name (Legal Business Name): TORY L DOTSON OD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MIMOSA LN
TAHLEQUAH OK
74464-5703
US

IV. Provider business mailing address

105 MIMOSA LN
TAHLEQUAH OK
74464-5703
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-9939
  • Fax: 918-453-9945
Mailing address:
  • Phone: 918-431-9939
  • Fax: 918-431-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2649
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier200299660A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: DR. TORY L DOTSON
Title or Position: DOCTOR/ OWNER
Credential: OD
Phone: 918-431-9939