Provider Demographics
NPI:1225301443
Name:GAYDOS, MICHAEL WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:GAYDOS
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 1:8430 N 123RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2130
Mailing Address - Country:US
Mailing Address - Phone:918-510-6432
Mailing Address - Fax:
Practice Address - Street 1:14140 N MANDY RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0658
Practice Address - Country:US
Practice Address - Phone:918-510-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-18
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK369786ZLASMedicare UPIN