Provider Demographics
NPI:1942280896
Name:BERENSON, THOMAS HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HOWARD
Last Name:BERENSON
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 1:3300 S ASPEN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7501
Mailing Address - Country:US
Mailing Address - Phone:918-451-2020
Mailing Address - Fax:918-449-9086
Practice Address - Street 1:3300 S ASPEN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7501
Practice Address - Country:US
Practice Address - Phone:918-451-2020
Practice Address - Fax:918-449-9086
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765420AMedicaid
OK100765420AMedicaid
OK0657040001Medicare NSC
OK$$$$$$$$$Medicare PIN