Provider Demographics
NPI:1609879238
Name:RILEY, JUDITH ANN (OD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:RILEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:DICKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1402 N. SIOUX
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017
Mailing Address - Country:US
Mailing Address - Phone:918-341-3284
Mailing Address - Fax:918-341-3127
Practice Address - Street 1:1402 N. SIOUX
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017
Practice Address - Country:US
Practice Address - Phone:918-341-3284
Practice Address - Fax:918-341-3127
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5764055OtherAETNA
OK2226424OtherUNITED HEALTHCARE
OK100759950DMedicaid
OK2226424OtherUNITED HEALTHCARE
OKT40621Medicare UPIN