Provider Demographics
NPI:1750300992
Name:CHENOWETH, CHRISTOPHER RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:RAY
Last Name:CHENOWETH
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 1:502 E PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-7404
Mailing Address - Country:US
Mailing Address - Phone:580-765-7509
Mailing Address - Fax:580-765-2886
Practice Address - Street 1:502 E PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-7404
Practice Address - Country:US
Practice Address - Phone:580-765-7509
Practice Address - Fax:580-765-2886
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2154152WC0802X, 152WP0200X, 152WS0006X, 332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744700AMedicaid
OK1053280001Medicare NSC
OK100744700AMedicaid
OKOKA103651Medicare PIN