Basic Information
| Provider Information | |||||||||
| NPI: | 1669635751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744647017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184444000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744647017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184444000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2595 | CO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2633 | OK | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.