Provider Demographics
NPI:1164416574
Name:FENTON, OLIN W (OD)
Entity Type:Individual
Prefix:MR
First Name:OLIN
Middle Name:W
Last Name:FENTON
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 1:200 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2402
Mailing Address - Country:US
Mailing Address - Phone:918-567-3424
Mailing Address - Fax:918-567-3420
Practice Address - Street 1:200 DALLAS ST
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2402
Practice Address - Country:US
Practice Address - Phone:918-567-3424
Practice Address - Fax:918-567-3420
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6474TG152W00000X
OK2417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81289QOtherTEXAS BCBS PROVIDER NUMBE
TX8B2595Medicare ID - Type UnspecifiedTEXAS MEDICARE NUMBER
TX81289QOtherTEXAS BCBS PROVIDER NUMBE
TX1223950001Medicare NSC
OKOKA102213Medicare PIN