Provider Demographics
NPI:1912100215
Name:GARY L. WADE, O.D., INC
Entity Type:Organization
Organization Name:GARY L. WADE, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-794-2020
Mailing Address - Street 1:306 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6707
Mailing Address - Country:US
Mailing Address - Phone:405-794-2020
Mailing Address - Fax:405-794-3768
Practice Address - Street 1:306 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6707
Practice Address - Country:US
Practice Address - Phone:405-794-2020
Practice Address - Fax:405-794-3768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK448547920Medicare ID - Type Unspecified
OKT40699Medicare UPIN
OKOKA103523Medicare PIN