Provider Demographics
NPI:1730387846
Name:JOHN B. MINNETT, O.D. INC.
Entity type:Organization
Organization Name:JOHN B. MINNETT, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTEN
Authorized Official - Middle Name:ROBERSON
Authorized Official - Last Name:CLIFT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-224-5342
Mailing Address - Street 1:619 W CHICKASHA AVE
Mailing Address - Street 2:P.O. BOX 1599
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2413
Mailing Address - Country:US
Mailing Address - Phone:405-224-5342
Mailing Address - Fax:405-222-2819
Practice Address - Street 1:619 W CHICKASHA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2413
Practice Address - Country:US
Practice Address - Phone:405-224-5342
Practice Address - Fax:405-222-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2155152WC0802X, 152WP0200X, 332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732660AMedicaid
410017130OtherRAILROAD MEDICARE
OK=========-001OtherBLUE CROSS BLUE SHIELD OF OKLAHOMA
410017130OtherRAILROAD MEDICARE
OK=========-001OtherBLUE CROSS BLUE SHIELD OF OKLAHOMA