Provider Demographics
NPI:1093787574
Name:GENTRY, JAMES MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MATTHEW
Last Name:GENTRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 SW 119TH ST
Mailing Address - Street 2:STEB
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-2625
Mailing Address - Country:US
Mailing Address - Phone:405-735-3333
Mailing Address - Fax:
Practice Address - Street 1:2601 SW 119TH ST STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170
Practice Address - Country:US
Practice Address - Phone:405-735-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2420152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1502420Medicaid
OK200162110 AMedicaid
OK200162110 AMedicaid