Provider Demographics
NPI:1629084215
Name:HISKETT, ROY D (OD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:D
Last Name:HISKETT
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:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-0719
Mailing Address - Country:US
Mailing Address - Phone:918-367-2020
Mailing Address - Fax:918-367-9542
Practice Address - Street 1:121 E 7TH
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2501
Practice Address - Country:US
Practice Address - Phone:918-367-2020
Practice Address - Fax:918-367-9542
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761340AMedicaid
OK0331570001Medicare NSC
OKOK700136Medicare PIN
OK100761340AMedicaid