Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 973 | OK |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 973 | OK |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | 973 | OK |
N | 152WP0200X | Pediatric Optomitrist | 973 | OK |
N | 152WS0006X | Sports Vision | 973 | OK |
N | 152WV0400X | Optomitrist - Vision Therapist | 973 | OK |
N | 152WX0102X | Occupational Vision | 973 | OK |
NPI | 1205839685 |
---|---|
Provider Name | Mr. Max L Carlisle |
First Address | Fairview, OK 73737-2124 |
Second Address | Fairview, OK 73737-2124 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2005 |
Last Update Date | 23/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0246290001 | PALMETTO DMERC (01) | OK |
100766110A | (05) | OK |
410046324 | RAILROAD MEDICARE (01) | OK |
T40382 | (02) | OK |