Provider Demographics
NPI:1073921524
Name:CARLISLE, BLAKE (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:CARLISLE
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 1:111 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-2124
Mailing Address - Country:US
Mailing Address - Phone:580-227-4878
Mailing Address - Fax:580-227-4666
Practice Address - Street 1:111 E BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-2124
Practice Address - Country:US
Practice Address - Phone:580-227-4878
Practice Address - Fax:580-227-4666
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2804152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist