Provider Demographics
NPI:1467444315
Name:DORMAN, GARY A
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:DORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FAIRVIEW AVE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1922
Mailing Address - Country:US
Mailing Address - Phone:580-765-3356
Mailing Address - Fax:580-765-3353
Practice Address - Street 1:400 FAIRVIEW AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1922
Practice Address - Country:US
Practice Address - Phone:580-765-3356
Practice Address - Fax:580-765-3353
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100764410AMedicaid
OK7311837180001OtherBLUE CROSS/BLUE SHIELD
OK0982390001Medicare NSC
OKT40423Medicare UPIN