Provider Demographics
NPI:1790726842
Name:BRIAN, MICHAEL L (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:BRIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:HENRYETTA
Other - Middle Name:EYE
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:900 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-4252
Mailing Address - Country:US
Mailing Address - Phone:918-652-2345
Mailing Address - Fax:918-652-2537
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4252
Practice Address - Country:US
Practice Address - Phone:918-652-2345
Practice Address - Fax:918-652-2537
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1024152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763680AMedicaid
OK410036906OtherRAIL ROAD MEDICARE
OKP00711249OtherRAIL ROAD MEDICARE
OK$$$$$$$$$Medicare PIN
OKT40371Medicare UPIN
OK100763680AMedicaid