Provider Demographics
NPI:1316103401
Name:MAYES, AMBER ANN (OD)
Entity type:Individual
Prefix:DR
First Name:AMBER
Middle Name:ANN
Last Name:MAYES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6239
Mailing Address - Country:US
Mailing Address - Phone:405-880-0352
Mailing Address - Fax:
Practice Address - Street 1:4520 S HARVARD AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2925
Practice Address - Country:US
Practice Address - Phone:918-745-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA100421Medicare PIN