Provider Demographics
NPI:1750465340
Name:OKLAHOMA RETINA PLLC
Entity Type:Organization
Organization Name:OKLAHOMA RETINA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:ELIAS
Authorized Official - Last Name:SROUJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-945-4848
Mailing Address - Street 1:3435 NW 56TH ST
Mailing Address - Street 2:STE 808
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-945-4848
Mailing Address - Fax:405-945-4846
Practice Address - Street 1:3435 NW 56TH ST
Practice Address - Street 2:STE 808
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-945-4848
Practice Address - Fax:405-945-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
731532364731120000OtherTRICARE
OK200071590AMedicaid
448706812005OtherBCBS
448706812005OtherBLUE LINCS
731532364731120000OtherTRICARE