Provider Demographics
NPI:1316165491
Name:WAYMON D. HARRISON, O.D. P.C.
Entity type:Organization
Organization Name:WAYMON D. HARRISON, O.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYMON
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-691-2210
Mailing Address - Street 1:11653 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5801
Mailing Address - Country:US
Mailing Address - Phone:405-691-2210
Mailing Address - Fax:405-691-0136
Practice Address - Street 1:11653 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5801
Practice Address - Country:US
Practice Address - Phone:405-691-2210
Practice Address - Fax:405-691-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA104121Medicare PIN
OKU37724Medicare UPIN
OK443602688MMedicare ID - Type Unspecified