MEDICARE: DR. GEORGE MARK REDWINE O.D.

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	152W00000X	Optometrist	822	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235109232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE MARK REDWINE O.D.

Provider Business Mailing Address
First Line	:	4720 N CLASSEN BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-4827
Country	:	US
Telephone Number	:	405-528-1207
Fax Number	:	405-528-0279

Provider Business Practice Location Address
First Line	:	4720 N CLASSEN BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-4827
Country	:	US
Telephone Number	:	405-528-1207
Fax Number	:	405-528-0279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	12/16/2009

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