1275983777 NPI number — DR. MILLARD LAFAYETTE HENRY III M.D.

Table of content: DR. MILLARD LAFAYETTE HENRY III M.D. (NPI 1275983777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275983777 NPI number — DR. MILLARD LAFAYETTE HENRY III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
MILLARD
Provider Middle Name:
LAFAYETTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.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:
1275983777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 N INDEPENDENCE AVE STE 280
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:
73112-5555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-636-7499
Provider Business Mailing Address Fax Number:
405-636-7809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 S DOUGLAS AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73109-3215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-636-7499
Provider Business Practice Location Address Fax Number:
405-636-7809
Provider Enumeration Date:
06/15/2016

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: 208800000X , with the licence number:  32424 , 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)





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