Provider Demographics
NPI:1811058589
Name:BRAGG, EVAN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:LEE
Last Name:BRAGG
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 499
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-0499
Mailing Address - Country:US
Mailing Address - Phone:580-622-2020
Mailing Address - Fax:580-622-3213
Practice Address - Street 1:1010 WEST 3RD ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-0499
Practice Address - Country:US
Practice Address - Phone:580-622-2020
Practice Address - Fax:580-622-3213
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100765070AMedicaid
OK100765070AMedicaid
OKT40368Medicare UPIN