Provider Demographics
NPI:1386330603
Name:GERSTEIN, ETHAN JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOSEPH
Last Name:GERSTEIN
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 1:203 S RIVERFRONT DR APT 102
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5676
Mailing Address - Country:US
Mailing Address - Phone:615-939-1778
Mailing Address - Fax:
Practice Address - Street 1:1101 S BELMONT AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6315
Practice Address - Country:US
Practice Address - Phone:918-300-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist