Provider Demographics
NPI:1164586699
Name:WATTERS, MICHAEL BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:WATTERS
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 1:2020 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-3141
Mailing Address - Country:US
Mailing Address - Phone:405-273-7075
Mailing Address - Fax:405-273-7405
Practice Address - Street 1:2020 N HARRISON
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-273-7075
Practice Address - Fax:405-273-7405
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK249506101OtherMEDICARE PROVIDER NUMBER
OK200034440AMedicaid
OK5320170001Medicare NSC