Provider Demographics
NPI:1508910498
Name:RODDY, KEN COY (OD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:COY
Last Name:RODDY
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 1:1010 N PENNSYLVANIA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-6412
Mailing Address - Country:US
Mailing Address - Phone:405-236-2020
Mailing Address - Fax:405-236-2020
Practice Address - Street 1:1010 N PENNSYLVANIA AVE
Practice Address - Street 2:STE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6412
Practice Address - Country:US
Practice Address - Phone:405-236-2020
Practice Address - Fax:405-236-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK1140152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40628Medicare UPIN