1083041966 NPI number — GORDON P. LAIRD, D.O. INC

Table of content: (NPI 1083041966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083041966 NPI number — GORDON P. LAIRD, D.O. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON P. LAIRD, D.O. INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083041966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39451 E 41 RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73061-9686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-363-0052
Provider Business Mailing Address Fax Number:
580-363-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 ILLINOIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWNEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74058-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-762-3602
Provider Business Practice Location Address Fax Number:
580-363-0894
Provider Enumeration Date:
10/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LAIRD
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
580-363-0052

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 1532 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100128350F , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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