Provider Demographics
NPI:1487673489
Name:PENISTEN, DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:PENISTEN
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 1:1001 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-456-5511
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7017
Practice Address - Country:US
Practice Address - Phone:918-458-2109
Practice Address - Fax:918-458-2310
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100760370AMedicaid
OK248235420Medicare PIN
OK100760370AMedicaid