1467487132 NPI number — STILLWATER DERMATOLOGY CLINIC

Table of content: (NPI 1467487132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467487132 NPI number — STILLWATER DERMATOLOGY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STILLWATER DERMATOLOGY CLINIC
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:
1467487132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1583
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74076-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-533-3376
Provider Business Mailing Address Fax Number:
405-533-2642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1329 S SANGRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74074-1854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-533-3376
Provider Business Practice Location Address Fax Number:
405-533-2642
Provider Enumeration Date:
07/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
CARL
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
405-533-3376

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  22869 , 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)