Provider Demographics
NPI:1558379669
Name:NOLAN, J DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:J DEAN
Middle Name:
Last Name:NOLAN
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 1:3414 NW CACHE RD STE E
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3877
Mailing Address - Country:US
Mailing Address - Phone:580-353-2015
Mailing Address - Fax:580-353-2022
Practice Address - Street 1:3414 NW CACHE RD STE E
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3877
Practice Address - Country:US
Practice Address - Phone:580-353-2015
Practice Address - Fax:580-353-2022
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765020AMedicaid
1780858464OtherTYPE 2 ORGANIZATION NPI
OK100765020AMedicaid