Healthcare Provider Details

I. General information

NPI: 1992732119
Provider Name (Legal Business Name): KIMBERLY DAWN DUROSSETTE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 CHANDLER RD
MUSKOGEE OK
74403-4911
US

IV. Provider business mailing address

3505 CHANDLER RD
MUSKOGEE OK
74403-4911
US

V. Phone/Fax

Practice location:
  • Phone: 918-880-3937
  • Fax: 918-539-0030
Mailing address:
  • Phone: 918-880-3937
  • Fax: 918-539-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2359
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: