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General NPI Number Information
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NPI Number | 1053423947
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Entity Type | Organization
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Legal Business Name | PEDIATRIC OPHTHALMOLOGY, PC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 01/23/2020
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Provider Practice Location Address
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Address Line | 4606 E 67TH ST SUITE 400
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City | TULSA
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State | OK
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Zip | 74136-4943
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Country | US
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Telephone | 918-481-2738
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Fax | 918-481-2785
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Provider Business Mailing Address
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Address Line | 4606 E 67TH ST STE 400
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City | TULSA
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State | OK
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Zip | 74136-4950
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Country | US
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Telephone | 918-986-8585
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Fax | 918-728-8492
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY THANE DENSLOW
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Credential | MD
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Telephone | 918-949-9898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 038654
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License Number State | OK
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