Provider Demographics
NPI:1982719571
Name:RAINWATER, WESLEY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:ALAN
Last Name:RAINWATER
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 1:8122 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4309
Mailing Address - Country:US
Mailing Address - Phone:918-254-0447
Mailing Address - Fax:918-252-5753
Practice Address - Street 1:8122 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4309
Practice Address - Country:US
Practice Address - Phone:918-254-0447
Practice Address - Fax:918-252-5753
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK985152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100759910AMedicaid
OK100759910AMedicaid
OKT40614Medicare UPIN