Provider Demographics
NPI:1649283953
Name:MCMULLIN, GERALD W (OD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:MCMULLIN
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 1:922 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:405-375-3128
Mailing Address - Fax:405-375-3134
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:405-375-3134
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100766080AMedicaid
OK730941249-001OtherBLUE CROSS/BLUE SHIELD
OK730941249-001OtherBLUE CROSS/BLUE SHIELD