Provider Demographics
NPI:1386725224
Name:SOUTHWEST EYE CLINIC, PLLC
Entity type:Organization
Organization Name:SOUTHWEST EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-631-1527
Mailing Address - Street 1:1240 SW 44TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3604
Mailing Address - Country:US
Mailing Address - Phone:405-631-1527
Mailing Address - Fax:405-631-9930
Practice Address - Street 1:1240 SW 44TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3604
Practice Address - Country:US
Practice Address - Phone:405-631-1527
Practice Address - Fax:405-631-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2024-08-06
Deactivation Date:2024-07-11
Deactivation Code:
Reactivation Date:2024-08-06
Provider Licenses
StateLicense IDTaxonomies
OK208D00000X208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100059640AMedicaid