Provider Demographics
NPI:1902936347
Name:OMNI EYE CENTER EDMOND INC.
Entity Type:Organization
Organization Name:OMNI EYE CENTER EDMOND INC.
Other - Org Name:OMNI EYE CENTER - LASER VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-478-4444
Mailing Address - Street 1:1333 WEST 33RD STREET
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6306
Mailing Address - Country:US
Mailing Address - Phone:405-478-4444
Mailing Address - Fax:405-478-4497
Practice Address - Street 1:1333 WEST 33RD STREET
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6306
Practice Address - Country:US
Practice Address - Phone:405-478-4444
Practice Address - Fax:405-478-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731396793001OtherBLUE CROSS BLUE SHIELD
OK0968340001OtherCIGNA GOVERNMENT SERVICES DMERC
OK900522001Medicare PIN
OK0968340001Medicare NSC