Healthcare Provider Details

I. General information

NPI: 1184553554
Provider Name (Legal Business Name): ETHAN GRAHAM CHANDLER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CREEK PL
OKMULGEE OK
74447-6730
US

IV. Provider business mailing address

3505 W 112TH ST S
JENKS OK
74037-2493
US

V. Phone/Fax

Practice location:
  • Phone: 918-756-0316
  • Fax:
Mailing address:
  • Phone: 316-650-9939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3336
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: