Provider Demographics
NPI:1063415396
Name:GUTHRIE EYE CARE CLINIC, INC.
Entity type:Organization
Organization Name:GUTHRIE EYE CARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-260-2020
Mailing Address - Street 1:2114 W NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-2116
Mailing Address - Country:US
Mailing Address - Phone:405-260-2020
Mailing Address - Fax:405-282-8886
Practice Address - Street 1:2114 W NOBLE AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-2116
Practice Address - Country:US
Practice Address - Phone:405-260-2020
Practice Address - Fax:405-282-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2032152W00000X
OK1193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
043728001OtherDMERC
OK100745070AMedicaid
043728001OtherDMERC