Provider Demographics
NPI:1235195975
Name:GLECKLER, MARSHALL R (O D)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:R
Last Name:GLECKLER
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1439
Mailing Address - Country:US
Mailing Address - Phone:405-275-7676
Mailing Address - Fax:405-275-6837
Practice Address - Street 1:100 E 45TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1439
Practice Address - Country:US
Practice Address - Phone:405-275-7676
Practice Address - Fax:405-275-6837
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761410AMedicaid
0388250001Medicare NSC
OKT40468Medicare UPIN