1467660803 NPI number — DOUGLAS O BRADY PH.D.

Table of content: DOUGLAS O BRADY PH.D. (NPI 1467660803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467660803 NPI number — DOUGLAS O BRADY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADY
Provider First Name:
DOUGLAS
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1467660803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6446
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73506-0446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-355-7474
Provider Business Mailing Address Fax Number:
580-355-6765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6601 W GORE BLVD.
Provider Second Line Business Practice Location Address:
#6446
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-355-7474
Provider Business Practice Location Address Fax Number:
580-355-6765
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  21363 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 198 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 731279230001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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