Provider Demographics
NPI:1023295839
Name:GARY A DORMAN
Entity type:Organization
Organization Name:GARY A DORMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-765-3356
Mailing Address - Street 1:400 FAIRVIEW
Mailing Address - Street 2:SUITE 21
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1922
Mailing Address - Country:US
Mailing Address - Phone:580-765-3356
Mailing Address - Fax:580-765-3353
Practice Address - Street 1:400 FAIRVIEW
Practice Address - Street 2:SUITE 21
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1922
Practice Address - Country:US
Practice Address - Phone:580-765-3356
Practice Address - Fax:580-765-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1043332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0982390001Medicare NSC