Healthcare Provider Details

I. General information

NPI: 1689704702
Provider Name (Legal Business Name): DR CHARLES W GURLEY OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W 12TH ST
ADA OK
74820-6404
US

IV. Provider business mailing address

216 W 12TH ST
ADA OK
74820-6404
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-5606
  • Fax: 580-332-3946
Mailing address:
  • Phone: 580-332-5606
  • Fax: 580-332-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1108
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1108
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier100741180A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MRS. LEQUITA M. GURLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-332-5606