Healthcare Provider Details

I. General information

NPI: 1194718775
Provider Name (Legal Business Name): GARY THANE DENSLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 E 67TH ST STE 400
TULSA OK
74136-4950
US

IV. Provider business mailing address

4606 E 67TH ST STE 400
TULSA OK
74136-4950
US

V. Phone/Fax

Practice location:
  • Phone: 918-938-6442
  • Fax: 918-728-8091
Mailing address:
  • Phone: 918-949-9898
  • Fax: 918-728-8091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number11608
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number11608
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: