Provider Demographics
NPI:1376761627
Name:HART-CARLOCK, ELIZABETH M (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:HART-CARLOCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6506
Mailing Address - Country:US
Mailing Address - Phone:405-876-6393
Mailing Address - Fax:
Practice Address - Street 1:2000 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6506
Practice Address - Country:US
Practice Address - Phone:405-876-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003209152W00000X
OK3130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU57580Medicare UPIN