MEDICARE: OKLAHOMA EYE INSTITUTE PROCEDURES LLC

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	261QS0132X	Ophthalmologic Surgery Clinic/Center
2	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1053096321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA EYE INSTITUTE PROCEDURES LLC

Provider Business Mailing Address
First Line	:	1020 N MAIN ST
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-2831
Country	:	US
Telephone Number	:	580-225-1555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 N MAIN ST
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-2831
Country	:	US
Telephone Number	:	580-225-1555
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	KAMRAN MASSOUMI
Credential	:	MD
Telephone Number	:	580-225-1555

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	07/07/2023

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