MEDICARE: KEN RODDY O.D., 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	152W00000X	Optometrist	1140	OK

General Provider Information

NPI Number	:	1487993150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEN RODDY O.D., PLLC

Provider Business Mailing Address
First Line	:	1010 N PENNSYLVANIA AVE
Second Line	:	STE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-6412
Country	:	US
Telephone Number	:	405-236-2020
Fax Number	:	405-236-5001

Provider Business Practice Location Address
First Line	:	1010 N PENNSYLVANIA AVE
Second Line	:	STE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-6412
Country	:	US
Telephone Number	:	405-236-2020
Fax Number	:	405-236-5001

Authorized Official
Title or Position	:	OWNER
Name	:	KENNETH RODDY
Credential	:	OD
Telephone Number	:	405-236-2020

Provider Enumeration Date	:	01/31/2013
Last Update Date	:	08/11/2015

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