Provider Demographics
NPI:1992920144
Name:BONAVISION EYE CENTER, PC
Entity type:Organization
Organization Name:BONAVISION EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:H
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-206-4445
Mailing Address - Street 1:2815 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-5419
Mailing Address - Country:US
Mailing Address - Phone:405-528-8200
Mailing Address - Fax:405-528-8201
Practice Address - Street 1:2815 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5419
Practice Address - Country:US
Practice Address - Phone:405-528-8200
Practice Address - Fax:405-528-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100748350AMedicaid
OK4379520002Medicare NSC