Healthcare Provider Details

I. General information

NPI: 1922836550
Provider Name (Legal Business Name): ABBIE ETTER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 S OAK ST
SAPULPA OK
74066-4312
US

IV. Provider business mailing address

207 W DAVIS AVE
SAPULPA OK
74066-5503
US

V. Phone/Fax

Practice location:
  • Phone: 918-224-2610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3260
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3260
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3260
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: