Individual
MICHAEL BRIAN WATTERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
2020 N HARRISON, SHAWNEE, OK 74804
(405) 273-7075
(405) 273-7405
Mailing address
2020 N HARRISON ST, SHAWNEE, OK 74804-3141
(405) 273-7075
(405) 273-7405
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2408
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200034440A
—
OK
01
—
249506101
MEDICARE PROVIDER NUMBER
OK
Enumeration date
12/20/2006
Last updated
07/31/2013
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