MEDICARE: DR. FRED WILLY HERRIN III OD

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	878	OK

General Provider Information

NPI Number	:	1548349525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED WILLY HERRIN III OD

Provider Business Mailing Address
First Line	:	10308 MANTLE DR
Second Line	:
City	:	OKLAYHOMA CITY
State	:	OK
Zip	:	73162
Country	:	US
Telephone Number	:	405-722-3993
Fax Number	:

Provider Business Practice Location Address
First Line	:	7222 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132
Country	:	US
Telephone Number	:	405-721-0100
Fax Number	:	405-720-7915

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

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	07/08/2007

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