Healthcare Provider Details

I. General information

NPI: 1447244827
Provider Name (Legal Business Name): PEDIATRIC OPHTHALMOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 E 67TH ST STE 400
TULSA OK
74136-4943
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY THANE DENSLOW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 918-949-9898