Provider Demographics
NPI:1861679300
Name:HOGLE, JUSTIN WARREN (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WARREN
Last Name:HOGLE
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 1:2500 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-5003
Mailing Address - Country:US
Mailing Address - Phone:918-683-3937
Mailing Address - Fax:918-683-3945
Practice Address - Street 1:2500 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-5003
Practice Address - Country:US
Practice Address - Phone:918-683-3937
Practice Address - Fax:918-683-3945
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200066920AMedicaid
OK400522525Medicare PIN
OK5768860001Medicare NSC
OKV07545Medicare UPIN