MEDICARE: DR. LISA MARIE KEDZUF-MCGINNIS O.D.

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	2477	OK

General Provider Information

NPI Number	:	1134216609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA MARIE KEDZUF-MCGINNIS O.D.

Provider Business Mailing Address
First Line	:	9318 SCARLET OAK DR
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-3901
Country	:	US
Telephone Number	:	918-520-4344
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 S BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-4614
Country	:	US
Telephone Number	:	918-358-2245
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/06/2022

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