Provider Demographics
NPI:1992732119
Name:DUROSSETTE, KIMBERLY DAWN (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:DAWN
Last Name:DUROSSETTE
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4911
Mailing Address - Country:US
Mailing Address - Phone:918-880-3937
Mailing Address - Fax:918-539-0030
Practice Address - Street 1:3505 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4911
Practice Address - Country:US
Practice Address - Phone:918-880-3937
Practice Address - Fax:918-539-0030
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200006780AMedicaid