Provider Demographics
NPI:1245215524
Name:WADE, GARY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:WADE
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 1:306 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6707
Mailing Address - Country:US
Mailing Address - Phone:405-794-2020
Mailing Address - Fax:405-794-3768
Practice Address - Street 1:306 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6707
Practice Address - Country:US
Practice Address - Phone:405-794-2020
Practice Address - Fax:405-794-3768
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100766050AMedicaid
OKT40699Medicare UPIN
OKOKA103524Medicare PIN