Healthcare Provider Details

I. General information

NPI: 1649211301
Provider Name (Legal Business Name): BRIAN R GUMM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 W 6TH AVE
STILLWATER OK
74074-4136
US

IV. Provider business mailing address

2123 W 6TH AVE
STILLWATER OK
74074-4136
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-3724
  • Fax: 405-743-1042
Mailing address:
  • Phone: 405-372-3724
  • Fax: 405-743-1042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1048
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: