Provider Demographics
NPI:1447244827
Name:PEDIATRIC OPHTHALMOLOGY, PC
Entity Type:Organization
Organization Name:PEDIATRIC OPHTHALMOLOGY, PC
Other - Org Name:PEDIATRIC AND FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:THANE
Authorized Official - Last Name:DENSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-949-9898
Mailing Address - Street 1:4606 E 67TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-4950
Mailing Address - Country:US
Mailing Address - Phone:918-949-9898
Mailing Address - Fax:918-949-9898
Practice Address - Street 1:4606 E 67TH ST
Practice Address - Street 2:STE 400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-4943
Practice Address - Country:US
Practice Address - Phone:918-949-9898
Practice Address - Fax:918-728-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522449Medicare ID - Type UnspecifiedMEDICARE