Provider Demographics
NPI:1265539613
Name:RADELL, ROGER LEE (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:RADELL
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:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-0507
Mailing Address - Country:US
Mailing Address - Phone:405-567-2261
Mailing Address - Fax:
Practice Address - Street 1:915 9TH STREET
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-0507
Practice Address - Country:US
Practice Address - Phone:405-567-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265539613OtherNPI
OK100766660AMedicaid
410042795Medicare PIN
U11168Medicare UPIN
903060002-001OtherBLUE CROSS BLUE SHIELD
OK1000766660AMedicaid