Healthcare Provider Details

I. General information

NPI: 1265539613
Provider Name (Legal Business Name): ROGER LEE RADELL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 9TH STREET
PRAGUE OK
74864-0507
US

IV. Provider business mailing address

PO BOX 507
PRAGUE OK
74864-0507
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-2261
  • Fax:
Mailing address:
  • Phone: 405-567-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2024
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: