1508095977 NPI number — DR. KYLE C WOODERSON D.O.

Table of content: DR. KYLE C WOODERSON D.O. (NPI 1508095977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508095977 NPI number — DR. KYLE C WOODERSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODERSON
Provider First Name:
KYLE
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1508095977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2017
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
Provider Second Line Business Mailing Address:
280
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-5556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-786-7300
Provider Business Mailing Address Fax Number:
918-786-7303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E 13TH ST
Provider Second Line Business Practice Location Address:
STE H
Provider Business Practice Location Address City Name:
GROVE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74344-2989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-786-7300
Provider Business Practice Location Address Fax Number:
918-786-7303
Provider Enumeration Date:
07/07/2009

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: 208600000X , with the licence number:  4824 , 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: 200254780A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200505990O , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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