Provider Demographics
NPI:1285134387
Name:MOTLEY VISION PROFESSIONALS, PLLC
Entity type:Organization
Organization Name:MOTLEY VISION PROFESSIONALS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-749-2020
Mailing Address - Street 1:21932 TOSCANA CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-0919
Mailing Address - Country:US
Mailing Address - Phone:405-329-5613
Mailing Address - Fax:
Practice Address - Street 1:9805 N. MAY AVENUE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-749-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2601152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200757780AMedicaid