Provider Demographics
NPI:1093704793
Name:GOURLEY, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:920 S BRYANT AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5797
Mailing Address - Country:US
Mailing Address - Phone:405-341-4238
Mailing Address - Fax:405-340-0269
Practice Address - Street 1:920 S BRYANT AVE
Practice Address - Street 2:STE 100
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5797
Practice Address - Country:US
Practice Address - Phone:405-341-4238
Practice Address - Fax:405-340-0269
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK10888207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100212730AMedicaid
248324103Medicare ID - Type Unspecified
OK100212730AMedicaid