Provider Demographics
NPI:1316069008
Name:MUSKOGEE REGIONAL EYE CLINIC INC
Entity type:Organization
Organization Name:MUSKOGEE REGIONAL EYE CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-687-9998
Mailing Address - Street 1:329 S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4945
Mailing Address - Country:US
Mailing Address - Phone:918-687-9998
Mailing Address - Fax:918-687-4135
Practice Address - Street 1:329 S 38TH ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4945
Practice Address - Country:US
Practice Address - Phone:918-687-9998
Practice Address - Fax:918-687-4135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11682174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS OF OKLAHOMA
OK=========001OtherBCBS OF OKLAHOMA
OKCJ3634Medicare PIN