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General NPI Number Information
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NPI Number | 1053542142
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Entity Type | Organization
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Legal Business Name | GORE EYE CLINIC PLLC
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Dates
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Enumeration Date | 08/06/2009
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Last Update Date | 01/07/2011
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Provider Practice Location Address
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Address Line | 202 N MAIN
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City | GORE
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State | OK
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Zip | 74435
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Country | US
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Telephone | 918-489-2512
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 712
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City | GORE
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State | OK
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Zip | 74435-0712
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Country | US
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Telephone | 918-489-2512
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JONI SUE RUSSELL
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Credential | OD
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Telephone | 918-489-2512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2470
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License Number State | OK
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