Provider Demographics
NPI:1588757603
Name:MORGAN, GARY R (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:MORGAN
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 1:2061 MAHANEY AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5731
Mailing Address - Country:US
Mailing Address - Phone:918-453-2000
Mailing Address - Fax:918-453-2008
Practice Address - Street 1:2061 MAHANEY AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5731
Practice Address - Country:US
Practice Address - Phone:918-453-2000
Practice Address - Fax:918-453-2008
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK925152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522259OtherMEDICARE PTAN
OK100762020AMedicaid
OK300522259OtherMEDICARE PTAN
OK100762020AMedicaid