1609900547 NPI number — MYRIAM DAWIS GILMORE M.D.

Table of content: MYRIAM DAWIS GILMORE M.D. (NPI 1609900547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609900547 NPI number — MYRIAM DAWIS GILMORE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
MYRIAM
Provider Middle Name:
DAWIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAWIS
Provider Other First Name:
MYRIAM
Provider Other Middle Name:
VILLAREAL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609900547
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 BRANDT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-458-5581
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S BLISS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-458-3120
Provider Business Practice Location Address Fax Number:
918-458-3511
Provider Enumeration Date:
03/15/2007

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: 208000000X , with the licence number:  N-6490 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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