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General NPI Number Information
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NPI Number | 1912100215
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Entity Type | Organization
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Legal Business Name | GARY L. WADE, O.D., INC
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/30/2012
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Provider Practice Location Address
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Address Line | 306 SE 4TH ST
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City | MOORE
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State | OK
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Zip | 73160-6707
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Country | US
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Telephone | 405-794-2020
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Fax | 405-794-3768
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Provider Business Mailing Address
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Address Line | 306 SE 4TH ST
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City | MOORE
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State | OK
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Zip | 73160-6707
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Country | US
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Telephone | 405-794-2020
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Fax | 405-794-3768
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY LEE WADE
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Credential | O.D.
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Telephone | 405-794-2020
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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 | 939
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License Number State | OK
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