Provider Demographics
NPI:1629357116
Name:CARLISLE, TREY DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:TREY
Middle Name:DEAN
Last Name:CARLISLE
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 1:712 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OK
Mailing Address - Zip Code:73932-3101
Mailing Address - Country:US
Mailing Address - Phone:580-625-2020
Mailing Address - Fax:
Practice Address - Street 1:712 AVE. A
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OK
Practice Address - Zip Code:73932
Practice Address - Country:US
Practice Address - Phone:580-625-2020
Practice Address - Fax:580-625-2021
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist