Provider Demographics
NPI:1205999471
Name:THOMAS H BERENSON O D P C
Entity type:Organization
Organization Name:THOMAS H BERENSON O D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:BERENSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-451-2020
Mailing Address - Street 1:3300 S ASPEN AVE
Mailing Address - Street 2:STE 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:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765420AMedicaid
OKMBO129824OtherDEA
OKOKAAA3156Medicare PIN
OKMBO129824OtherDEA