Organization
NORTHEASTERN STATE UNIVERSITY COLLEGE OF OPTOMETRY
Active
Other names
Northeastern State University Oklahoma College of Optometry
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DOUGLAS PENISTEN O.D. (DEAN)
(918) 456-5511
Entity
Organization
Contact information
Practice address
1001 N GRAND AVE, TAHLEQUAH, OK 74464-7017
(918) 458-2109
(918) 458-2310
Mailing address
1001 N GRAND AVE, TAHLEQUAH, OK 74464-7017
(918) 458-2109
(918) 458-2310
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
152WC0802X
Corneal and Contact Management Optometrist
—
—
152WL0500X
Low Vision Rehabilitation Optometrist
—
—
152WP0200X
Pediatric Optometrist
—
—
152WS0006X
Sports Vision Optometrist
—
—
152WV0400X
Vision Therapy Optometrist
—
—
152WX0102X
Occupational Vision Optometrist
—
—
207W00000X
Ophthalmology Physician
—
—
332H00000X
Eyewear Supplier
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100732440A
—
OK
Enumeration date
05/27/2006
Last updated
08/30/2010
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