Provider Demographics
NPI:1700915956
Name:SOUTHEASTERN OKLAHOMA EYE CLINIC
Entity type:Organization
Organization Name:SOUTHEASTERN OKLAHOMA EYE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-920-2020
Mailing Address - Street 1:1901 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3098
Mailing Address - Country:US
Mailing Address - Phone:580-920-2020
Mailing Address - Fax:580-924-5656
Practice Address - Street 1:1901 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3076
Practice Address - Country:US
Practice Address - Phone:580-920-2020
Practice Address - Fax:580-924-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200128560AMedicaid
OK200128560AMedicaid
OKOKB5019Medicare PIN