Provider Demographics
NPI:1558747295
Name:PONGSATIEN, JO (OD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:
Last Name:PONGSATIEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5350 E 31ST ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5011
Mailing Address - Country:US
Mailing Address - Phone:918-933-4075
Mailing Address - Fax:918-779-7794
Practice Address - Street 1:5350 E 31ST ST STE 302
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5008
Practice Address - Country:US
Practice Address - Phone:918-933-4075
Practice Address - Fax:918-779-7794
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist