Healthcare Provider Details

I. General information

NPI: 1194392134
Provider Name (Legal Business Name): TULSA EYE SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S COLUMBIA AVE STE 300
TULSA OK
74114-3518
US

IV. Provider business mailing address

5312 W 41ST ST
TULSA OK
74107-6110
US

V. Phone/Fax

Practice location:
  • Phone: 918-395-2020
  • Fax: 877-464-4002
Mailing address:
  • Phone: 918-800-2020
  • Fax: 877-464-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ROSE DAVYDOVA
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 918-800-2020