Provider Demographics
NPI:1124060371
Name:HARDIN, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3425
Mailing Address - Country:US
Mailing Address - Phone:580-889-9500
Mailing Address - Fax:580-889-9500
Practice Address - Street 1:902 W 13TH ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3425
Practice Address - Country:US
Practice Address - Phone:580-889-9500
Practice Address - Fax:580-889-9500
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100766210AMedicaid
OK100766210AMedicaid
OK$$$$$$$$$Medicare PIN
OK1288190001Medicare NSC