Provider Demographics
NPI:1255939377
Name:ELSTON, TORRY E
Entity type:Individual
Prefix:
First Name:TORRY
Middle Name:E
Last Name:ELSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 SE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110
Mailing Address - Country:US
Mailing Address - Phone:405-314-2260
Mailing Address - Fax:405-265-7788
Practice Address - Street 1:5908 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110
Practice Address - Country:US
Practice Address - Phone:405-314-2260
Practice Address - Fax:405-265-7788
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician