Provider Demographics
NPI:1861705931
Name:BOALDIN, CHRISTOPHER B (OD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:B
Last Name:BOALDIN
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 1:3908 PRESTON CT
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5019
Mailing Address - Country:US
Mailing Address - Phone:405-767-2020
Mailing Address - Fax:405-767-2022
Practice Address - Street 1:1901 NW EXPRESSWAY
Practice Address - Street 2:2058
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-1607
Practice Address - Country:US
Practice Address - Phone:405-767-2020
Practice Address - Fax:405-767-2022
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2640152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200344100AMedicaid