Provider Demographics
NPI:1053598391
Name:GLENN E. PARTIN OD PC
Entity type:Organization
Organization Name:GLENN E. PARTIN OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-376-9779
Mailing Address - Street 1:1100 N MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7201
Mailing Address - Country:US
Mailing Address - Phone:405-376-9779
Mailing Address - Fax:405-376-9668
Practice Address - Street 1:1100 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7201
Practice Address - Country:US
Practice Address - Phone:405-376-9779
Practice Address - Fax:405-376-9668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK410048385OtherRAILROAD MEDICARE
OK100759930AMedicaid
OK100759930AMedicaid
OK0679300001Medicare NSC
OKT40600Medicare UPIN