Provider Demographics
NPI:1225190655
Name:PAGE, RONNIE DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:DALE
Last Name:PAGE
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:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-5455
Mailing Address - Country:US
Mailing Address - Phone:405-527-3636
Mailing Address - Fax:405-527-5796
Practice Address - Street 1:300 SOUTH LESTER LANE STREET
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-5455
Practice Address - Country:US
Practice Address - Phone:405-527-3636
Practice Address - Fax:405-527-5796
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0733720001Medicare NSC