Healthcare Provider Details

I. General information

NPI: 1235109232
Provider Name (Legal Business Name): GEORGE MARK REDWINE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 N CLASSEN BLVD
OKLAHOMA CITY OK
73118-4827
US

IV. Provider business mailing address

4720 N CLASSEN BLVD
OKLAHOMA CITY OK
73118-4827
US

V. Phone/Fax

Practice location:
  • Phone: 405-528-1207
  • Fax: 405-528-0279
Mailing address:
  • Phone: 405-528-1207
  • Fax: 405-528-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number822
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: