Healthcare Provider Details

I. General information

NPI: 1720058654
Provider Name (Legal Business Name): TIMOTHY L NELSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 01/14/2013
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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: