Provider Demographics
NPI:1801070024
Name:VISION & EYE MEDICAL DIAGNOSTIC LASER CENTER
Entity type:Organization
Organization Name:VISION & EYE MEDICAL DIAGNOSTIC LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-266-3411
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-0098
Mailing Address - Country:US
Mailing Address - Phone:918-266-3411
Mailing Address - Fax:918-266-3412
Practice Address - Street 1:2310 NORTH HWY 66
Practice Address - Street 2:SUITE A
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-0098
Practice Address - Country:US
Practice Address - Phone:918-266-3411
Practice Address - Fax:918-266-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763100AMedicaid
OKT40428Medicare UPIN
OK443502947Medicare PIN