Healthcare Provider Details

I. General information

NPI: 1285736355
Provider Name (Legal Business Name): NELSON NELSON NELSON OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N NOBLE AVE
WATONGA OK
73772-0590
US

IV. Provider business mailing address

203 N NOBLE AVE
WATONGA OK
73772-0590
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-5073
  • Fax: 580-623-5020
Mailing address:
  • Phone: 580-623-5073
  • Fax: 580-623-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1011
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1011
License Number StateOK

VIII. Authorized Official

Name: DR. TIMOTHY LAYNE NELSON
Title or Position: OWNER
Credential: OD
Phone: 580-623-5073