=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497894844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY LYNN PETTIGREW O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 36TH AVE NW SUITE 120
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73072-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-366-1110
-----------------------------------------------------
Fax | 405-360-5749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 BOARDWALK
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73069-6372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-321-2155
-----------------------------------------------------
Fax | 405-321-1170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2176
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------