Provider Demographics
NPI:1235243544
Name:CARLSON, SCOTT MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:506 S CLEVELAND ST
Mailing Address - Street 2:STE B
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5523
Mailing Address - Country:US
Mailing Address - Phone:580-233-8200
Mailing Address - Fax:580-233-8200
Practice Address - Street 1:5335 W ROGERS BLVD
Practice Address - Street 2:STE B
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-5285
Practice Address - Country:US
Practice Address - Phone:198-396-4440
Practice Address - Fax:918-396-4449
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2017-03-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK2211152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100767350BMedicaid
OKOK700476Medicare PIN
OK1227920001Medicare NSC
OK6205560001Medicare NSC
OKU67453Medicare UPIN