MEDICARE: DR. KEN COY RODDY 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	OK1140	OK

General Provider Information

NPI Number	:	1508910498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEN COY RODDY O.D.

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	:	405-236-2020

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	:	405-236-2020

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	11/07/2014

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