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General NPI Number Information
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NPI Number | 1386330603
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Entity Type | Individual
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Provider Name | ETHAN JOSEPH GERSTEIN OD
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Gender | Male
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Dates
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Enumeration Date | 04/11/2023
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 1101 S BELMONT AVE
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City | OKMULGEE
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State | OK
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Zip | 74447-6315
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Country | US
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Telephone | 918-300-1480
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Fax |
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Provider Business Mailing Address
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Address Line | 203 S RIVERFRONT DR APT 102
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City | JENKS
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State | OK
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Zip | 74037-5676
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Country | US
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Telephone | 615-939-1778
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3222
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License Number State | OK
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