Individual
GARY A DORMAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
400 FAIRVIEW AVE, SUITE 21, PONCA CITY, OK 74601-1922
(580) 765-3356
(580) 765-3353
Mailing address
400 FAIRVIEW AVE, SUITE 21, PONCA CITY, OK 74601-1922
(580) 765-3356
(580) 765-3353
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1043
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100764410A
—
OK
01
—
7311837180001
BLUE CROSS/BLUE SHIELD
OK
Enumeration date
08/17/2005
Last updated
05/01/2009
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