Provider Demographics
NPI:1356470975
Name:HEAD, ROBERT DALE (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:HEAD
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 1:1302 SW C AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-4243
Mailing Address - Country:US
Mailing Address - Phone:580-355-1298
Mailing Address - Fax:580-581-7201
Practice Address - Street 1:1302 SW C AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4243
Practice Address - Country:US
Practice Address - Phone:580-355-1298
Practice Address - Fax:580-581-7201
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763770AMedicaid
OK731304648OtherEIN
OKT40490Medicare UPIN
OK0211960001Medicare NSC