MEDICARE: BONAVISION EYE CENTER, 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	152W00000X	Optometrist	OK2090	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992920144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONAVISION EYE CENTER, PC

Provider Business Mailing Address
First Line	:	2815 N CLASSEN BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5419
Country	:	US
Telephone Number	:	405-528-8200
Fax Number	:	405-528-8201

Provider Business Practice Location Address
First Line	:	2815 N CLASSEN BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5419
Country	:	US
Telephone Number	:	405-528-8200
Fax Number	:	405-528-8201

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. IRENE H LAM
Credential	:	OD
Telephone Number	:	405-206-4445

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	10/31/2023

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