1912124751 NPI number — STILLWATER VISION CLINIC INC

Table of content: (NPI 1912124751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912124751 NPI number — STILLWATER VISION CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STILLWATER VISION CLINIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912124751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2123 W 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74074-4136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-372-3724
Provider Business Mailing Address Fax Number:
405-743-1042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2123 W 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74074-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-372-3724
Provider Business Practice Location Address Fax Number:
405-743-1042
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUMM
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-372-3724

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 443721363001 . This is a "DAVID REYNOLDS,OD BCBS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100768660B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410033132 . This is a "BRIAN GUMM,O.D. RR MCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 448646516001 . This is a "BRIAN GUMM,OD BCBS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100766180A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410032462 . This is a "DAVID REYNOLDS,OD RRMCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200005020A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0210790001 . This is a "STILL VISION CL DMERC" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100766010A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410019936 . This is a "JAMES STARK,O.D. RR MCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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