Provider Demographics
NPI:1801924519
Name:SCOTT M. CARLSON OD PC
Entity type:Organization
Organization Name:SCOTT M. CARLSON OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-233-8200
Mailing Address - Street 1:506 S CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5523
Mailing Address - Country:US
Mailing Address - Phone:580-233-8200
Mailing Address - Fax:580-233-7510
Practice Address - Street 1:506 S CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5523
Practice Address - Country:US
Practice Address - Phone:580-233-8200
Practice Address - Fax:580-233-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2211152WC0802X, 152WP0200X, 152WS0006X, 156FX1201X, 156FX1800X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5196410001OtherDMERC
OK100749000AMedicaid
OK100767350AMedicaid
OK5196410001OtherDMERC
OKU67453Medicare UPIN
OK300522083Medicare ID - Type UnspecifiedGRP #