Provider Demographics
NPI:1013010289
Name:RODDY, DENISE (OD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:RODDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:6351 E. 67TH PL.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3506
Practice Address - Country:US
Practice Address - Phone:918-497-2002
Practice Address - Fax:918-497-2022
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1185152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762210AMedicaid
OK0458310001Medicare NSC
OK100762210AMedicaid