Basic Information
| Provider Information | |||||||||
| NPI: | 1174263792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | RAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221822442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 S HARVARD AVE STE 135 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187459662 | ||||||||
| FaxNumber: | 9187459663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2022 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3181 | OK | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.