Provider Demographics
NPI:1285252213
Name:MID-DEL VISION SOURCE PLLC
Entity type:Organization
Organization Name:MID-DEL VISION SOURCE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-732-2277
Mailing Address - Street 1:2008 S POST RD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6610
Mailing Address - Country:US
Mailing Address - Phone:405-732-2277
Mailing Address - Fax:405-737-4776
Practice Address - Street 1:1 NE 2ND ST STE 104
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-2224
Practice Address - Country:US
Practice Address - Phone:405-732-2277
Practice Address - Fax:405-737-4776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-DEL VISION SOURCE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty