Provider Demographics
NPI:1366505448
Name:GLENPOOL EYE CARE, PLLC
Entity Type:Organization
Organization Name:GLENPOOL EYE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:GOSNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-291-1222
Mailing Address - Street 1:247 E. 141ST ST.
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033
Mailing Address - Country:US
Mailing Address - Phone:918-291-1222
Mailing Address - Fax:
Practice Address - Street 1:247 E. 141ST ST.
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033
Practice Address - Country:US
Practice Address - Phone:918-291-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA103549Medicare PIN