Provider Demographics
NPI:1104816289
Name:SNODGRASS, BLANE ELDON (OD)
Entity type:Individual
Prefix:DR
First Name:BLANE
Middle Name:ELDON
Last Name:SNODGRASS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7171 S YALE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6367
Mailing Address - Country:US
Mailing Address - Phone:918-492-2702
Mailing Address - Fax:918-492-2256
Practice Address - Street 1:7171 S YALE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6367
Practice Address - Country:US
Practice Address - Phone:918-492-2702
Practice Address - Fax:918-492-2256
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT40661Medicare UPIN