Basic Information
| Provider Information | |||||||||
| NPI: | 1477623700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF OKLAHOMA HEAL SCI CTR COLLEGE OF MEDICINE OPHTHALMOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052713013 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 STANTON L YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716060 | ||||||||
| FaxNumber: | 4052713013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | GEIST | ||||||||
| AuthorizedOfficialFirstName: | GARYL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 4052715214 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200025250A | 05 | OK | MEDICAID |