Healthcare Provider Details

I. General information

NPI: 1093447898
Provider Name (Legal Business Name): CEDRICK MAH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 11/09/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

IV. Provider business mailing address

3749 SOUTHRIDGE CIR APT 4
TAHLEQUAH OK
74464-7928
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-4000
  • Fax:
Mailing address:
  • Phone: 918-570-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number3179
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: