Provider Demographics
NPI:1689704702
Name:DR CHARLES W GURLEY OD PC
Entity Type:Organization
Organization Name:DR CHARLES W GURLEY OD PC
Other - Org Name:ADVANCED EYE CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEQUITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-332-5606
Mailing Address - Street 1:216 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6404
Mailing Address - Country:US
Mailing Address - Phone:580-332-5606
Mailing Address - Fax:580-332-3946
Practice Address - Street 1:216 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6404
Practice Address - Country:US
Practice Address - Phone:580-332-5606
Practice Address - Fax:580-332-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1108152W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100741180AMedicaid
OKDG5527Medicare PIN
OK0380490001Medicare NSC
OK=========Medicare PIN