=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073921524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE CARLISLE O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 07/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 E BROADWAY
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73737-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-227-4878
-----------------------------------------------------
Fax | 580-227-4666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E BROADWAY
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73737-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-227-4878
-----------------------------------------------------
Fax | 580-227-4666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2804
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------