Healthcare Provider Details

I. General information

NPI: 1033259114
Provider Name (Legal Business Name): GRANT NASH CORNING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 01/17/2023
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 ARLINGTON ST
ADA OK
74820-2636
US

IV. Provider business mailing address

1425 ARLINGTON ST
ADA OK
74820-2636
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-1880
  • Fax: 580-332-2214
Mailing address:
  • Phone: 580-332-1880
  • Fax: 580-332-2214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25023
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200122220A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: