Provider Demographics
NPI:1316335615
Name:FAMILY EYE CARE OF SHAWNEE PLLC
Entity type:Organization
Organization Name:FAMILY EYE CARE OF SHAWNEE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:F
Authorized Official - Last Name:HOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-275-2020
Mailing Address - Street 1:2109 N KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2732
Mailing Address - Country:US
Mailing Address - Phone:405-275-2020
Mailing Address - Fax:405-275-4129
Practice Address - Street 1:2109 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2732
Practice Address - Country:US
Practice Address - Phone:405-275-2020
Practice Address - Fax:405-275-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
OK885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0577720001OtherPALMETTO
OK100764300AMedicaid
OK200463520AMedicaid
OK731350800001OtherBCBS
OK200463520AMedicaid
OK100764300AMedicaid