Provider Demographics
NPI:1952334906
Name:KISH, NICOLE M (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:KISH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4811
Mailing Address - Country:US
Mailing Address - Phone:405-573-9166
Mailing Address - Fax:405-573-9768
Practice Address - Street 1:3539 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4811
Practice Address - Country:US
Practice Address - Phone:405-573-9166
Practice Address - Fax:405-573-9768
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK400883Medicare PIN