MEDICARE: SAMUEL C. OLIPHANT, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	898	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	410022654	OTHER	OK	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1033244033	OTHER	OK	NPI, GROUP
3	1396750139	OTHER	OK	NPI INDIVIDUAL

General Provider Information

NPI Number	:	1033244033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMUEL C. OLIPHANT, INC

Provider Business Mailing Address
First Line	:	14000 QUAILBROOK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1701
Country	:	US
Telephone Number	:	405-751-7727
Fax Number	:	405-755-1875

Provider Business Practice Location Address
First Line	:	14000 QUAILBROOK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1701
Country	:	US
Telephone Number	:	405-751-7727
Fax Number	:	405-755-1875

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMUEL CURTIS OLIPHANT JR.
Credential	:	O.D.
Telephone Number	:	405-751-7727

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/01/2010

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