Provider Demographics
NPI:1679585566
Name:PAINTER, JON E (OD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:PAINTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4813
Mailing Address - Country:US
Mailing Address - Phone:405-799-7706
Mailing Address - Fax:405-799-7715
Practice Address - Street 1:619 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4813
Practice Address - Country:US
Practice Address - Phone:405-799-7706
Practice Address - Fax:405-799-7715
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762190AMedicaid
OK441729242001OtherBC/BS OK
OK100762190AMedicaid
OKP00837364Medicare PIN
OKOK700812Medicare UPIN
OKOK700812Medicare PIN