Provider Demographics
NPI:1104228105
Name:SHAWNEE EYE ASSOCIATES, PLLC
Entity type:Organization
Organization Name:SHAWNEE EYE ASSOCIATES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-275-7676
Mailing Address - Street 1:100 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1439
Mailing Address - Country:US
Mailing Address - Phone:405-275-7676
Mailing Address - Fax:405-275-6837
Practice Address - Street 1:100 E 45TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1439
Practice Address - Country:US
Practice Address - Phone:405-275-7676
Practice Address - Fax:405-275-6837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2690152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200350320AMedicaid