Provider Demographics
NPI:1285798835
Name:LAVERTY, RUSSELL (OD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:LAVERTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 S. POST ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130
Mailing Address - Country:US
Mailing Address - Phone:405-732-2277
Mailing Address - Fax:405-737-4776
Practice Address - Street 1:2008 S. POST ROAD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130
Practice Address - Country:US
Practice Address - Phone:405-732-2277
Practice Address - Fax:405-737-4776
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730942461OtherBCBS GROUP ID
OK730942461OtherTAX ID
OKCS4518OtherRAILROAD GROUP ID
OK410025669OtherRAILROAD MEDICARE PIN
OK730942461OtherMEDICARE GROUP PTAN
OKCS4518OtherRAILROAD GROUP ID
OK730942461OtherBCBS GROUP ID
OKCS4518OtherRAILROAD GROUP ID
OK730942461OtherMEDICARE GROUP PTAN