MEDICARE: GORE EYE CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	2470	OK

General Provider Information

NPI Number	:	1053542142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORE EYE CLINIC PLLC

Provider Business Mailing Address
First Line	:	PO BOX 712
Second Line	:
City	:	GORE
State	:	OK
Zip	:	74435-0712
Country	:	US
Telephone Number	:	918-489-2512
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 N MAIN
Second Line	:
City	:	GORE
State	:	OK
Zip	:	74435
Country	:	US
Telephone Number	:	918-489-2512
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. JONI SUE RUSSELL
Credential	:	OD
Telephone Number	:	918-489-2512

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	01/07/2011

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Directions to “GORE EYE CLINIC PLLC ” Practice Location

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