Provider Demographics
NPI:1477568293
Name:BRISCOE, MICHAEL K (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:BRISCOE
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 1:1400 BRYAN DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2156
Mailing Address - Country:US
Mailing Address - Phone:580-924-5211
Mailing Address - Fax:
Practice Address - Street 1:1400 BRYAN DR
Practice Address - Street 2:SUITE 303
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2156
Practice Address - Country:US
Practice Address - Phone:580-924-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T40373Medicare UPIN