Provider Demographics
NPI:1265588602
Name:GERALD W. MCMULLIN, O.D., INC.
Entity type:Organization
Organization Name:GERALD W. MCMULLIN, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-375-3128
Mailing Address - Street 1:922 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-4416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-4416
Practice Address - Country:US
Practice Address - Phone:405-375-3128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100766080AMedicaid
OKT40566Medicare UPIN