Provider Demographics
NPI:1679620199
Name:GELWICK, PHILLIP ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ALLEN
Last Name:GELWICK
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 1:1633 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6823
Mailing Address - Country:US
Mailing Address - Phone:918-744-7638
Mailing Address - Fax:918-744-5384
Practice Address - Street 1:1633 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-6823
Practice Address - Country:US
Practice Address - Phone:918-744-7638
Practice Address - Fax:918-744-5384
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK908152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT 40463Medicare UPIN