Provider Demographics
NPI:1154356590
Name:EVANS, WILLIAM LEE III (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
Last Name:EVANS
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:LEE
Other - Last Name:EVANS
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:100 EAST 2ND ST
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525
Mailing Address - Country:US
Mailing Address - Phone:580-889-3492
Mailing Address - Fax:580-889-3499
Practice Address - Street 1:100 EAST 2ND ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-0000
Practice Address - Country:US
Practice Address - Phone:580-889-3492
Practice Address - Fax:580-889-3499
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK959152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763170AMedicaid
OK731156847Medicare PIN
OK100763170AMedicaid
OK1154356590Medicare NSC