Healthcare Provider Details

I. General information

NPI: 1679205801
Provider Name (Legal Business Name): ALIA CAPPELLANI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

IV. Provider business mailing address

3775 SOUTHRIDGE CIR APT 11
TAHLEQUAH OK
74464-7941
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-5943
  • Fax:
Mailing address:
  • Phone: 918-708-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3165
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: