Provider Demographics
NPI:1235109232
Name:REDWINE, GEORGE MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MARK
Last Name:REDWINE
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 1:4720 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4827
Mailing Address - Country:US
Mailing Address - Phone:405-528-1207
Mailing Address - Fax:405-528-0279
Practice Address - Street 1:4720 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4827
Practice Address - Country:US
Practice Address - Phone:405-528-1207
Practice Address - Fax:405-528-0279
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765430AMedicaid
OKOK403822Medicare PIN
OKT40615Medicare UPIN
OK100765430AMedicaid