=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730823246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE PANKHURST OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2022
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 W UNIVERSITY BLVD
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-820-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 938 PANTHER LOOKOUT
-----------------------------------------------------
City | CALERA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74730-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-821-1116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3193
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------