MEDICARE: ENVISION MEDICAL & SURGICAL EYE CARE PC

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	207W00000X	Ophthalmology Physician	4949	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OKA102502	OTHER	OK	MEDICARE PTAN

General Provider Information

NPI Number	:	1811348766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENVISION MEDICAL & SURGICAL EYE CARE PC

Provider Business Mailing Address
First Line	:	4926 W KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-8517
Country	:	US
Telephone Number	:	918-605-7456
Fax Number	:	918-893-1724

Provider Business Practice Location Address
First Line	:	4926 W KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-8517
Country	:	US
Telephone Number	:	918-605-7456
Fax Number	:	918-893-1724

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MIRANDA KIRSTEN RENFROW
Credential	:	D.O.
Telephone Number	:	918-605-7456

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	06/22/2016

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