Provider Demographics
NPI:1851396873
Name:SHRECK, DWIGHT CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:CHARLES
Last Name:SHRECK
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 1:500 N WASHINGTON AVE. BOX 829
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096
Mailing Address - Country:US
Mailing Address - Phone:580-772-3232
Mailing Address - Fax:580-774-2020
Practice Address - Street 1:500 N WASHINGTON AVE. BOX 829
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-0829
Practice Address - Country:US
Practice Address - Phone:580-772-3232
Practice Address - Fax:580-774-2020
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40642Medicare UPIN