Provider Demographics
NPI:1275753550
Name:ROGER L RADELL O D INCORPORATED P C
Entity Type:Organization
Organization Name:ROGER L RADELL O D INCORPORATED P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RADELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-567-2261
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-0507
Mailing Address - Country:US
Mailing Address - Phone:405-567-2261
Mailing Address - Fax:
Practice Address - Street 1:915 9TH STREET
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-0507
Practice Address - Country:US
Practice Address - Phone:405-567-2261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275753550OtherNPI
OK200618310AMedicaid
OK100766660AMedicaid
903060002-001OtherBLUE CROSS BLUE SHIELD
DP0464Medicare PIN