Healthcare Provider Details

I. General information

NPI: 1649655549
Provider Name (Legal Business Name): ABIGAIL CHRISTINE GILLOGLY HARSCH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GRAND AVE NORTHEASTERN STATE UNIVERSITY OKLAHOMA COLLEGE OF OPTOM
TAHLEQUAH OK
74464-7017
US

IV. Provider business mailing address

607 W DELAWARE ST
TAHLEQUAH OK
74464-3615
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-4031
  • Fax:
Mailing address:
  • Phone: 605-929-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2850
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: