Basic Information
| Provider Information | |||||||||
| NPI: | 1386725224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST EYE CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 SW 44TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056311527 | ||||||||
| FaxNumber: | 4056319930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 SW 44TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056311527 | ||||||||
| FaxNumber: | 4056319930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MALLORY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4056311527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 208D00000X | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.