Individual
DR. FREDRICK J PEMBROKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
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) 456-5511
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
001
OK
152W00000X
Optometrist
882
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200055580A
—
OK
Enumeration date
07/19/2006
Last updated
08/31/2010
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