Provider Demographics
NPI:1205839685
Name:CARLISLE, MAX L (OD)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:L
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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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?:No
Enumeration Date:2005-05-31
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK973152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0246290001OtherPALMETTO DMERC
OK100766110AMedicaid
OK410046324OtherRAILROAD MEDICARE
OK0246290001OtherPALMETTO DMERC
OK243802401Medicare PIN