Provider Demographics
NPI:1053803635
Name:SOUTH TULSA VISION DEVELOPMENT
Entity type:Organization
Organization Name:SOUTH TULSA VISION DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND AR SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-872-8735
Mailing Address - Street 1:8988 S SHERIDAN RD STE D1
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5035
Mailing Address - Country:US
Mailing Address - Phone:918-949-4002
Mailing Address - Fax:918-949-4021
Practice Address - Street 1:8988 S SHERIDAN RD STE D1
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5035
Practice Address - Country:US
Practice Address - Phone:918-949-4002
Practice Address - Fax:918-949-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2784152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200545700AMedicaid