Provider Demographics
NPI:1124027313
Name:SELLERS, RONALD EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EDWARD
Last Name:SELLERS
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 1:1515 LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507
Mailing Address - Country:US
Mailing Address - Phone:580-353-0350
Mailing Address - Fax:580-355-6234
Practice Address - Street 1:1515 LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507
Practice Address - Country:US
Practice Address - Phone:580-353-0350
Practice Address - Fax:580-355-6234
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS2592Medicaid
8HZ59AMedicare ID - Type Unspecified
U86157Medicare UPIN