Provider Demographics
NPI:1588796049
Name:NICOLE M. KISH, O.D.,P.C.
Entity Type:Organization
Organization Name:NICOLE M. KISH, O.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-573-9166
Mailing Address - Street 1:3539 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4811
Mailing Address - Country:US
Mailing Address - Phone:405-573-9166
Mailing Address - Fax:405-573-9768
Practice Address - Street 1:3539 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4811
Practice Address - Country:US
Practice Address - Phone:405-573-9166
Practice Address - Fax:405-573-9768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK501158766Medicare PIN