Provider Demographics
NPI:1194718775
Name:DENSLOW, GARY THANE (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:THANE
Last Name:DENSLOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 E 67TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-4950
Mailing Address - Country:US
Mailing Address - Phone:918-949-9898
Mailing Address - Fax:918-728-8091
Practice Address - Street 1:4606 E 67TH ST STE 400
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-4950
Practice Address - Country:US
Practice Address - Phone:918-938-6442
Practice Address - Fax:918-728-8091
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11608207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100058220AMedicaid
OK100058220AMedicaid
OKC94848Medicare UPIN