1588795629 NPI number — CHARLES W GARRETT III, MD, INC

Table of content: (NPI 1588795629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588795629 NPI number — CHARLES W GARRETT III, MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES W GARRETT III, MD, INC
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:
1588795629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6606 S YALE AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74136-3364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-488-6608
Provider Business Mailing Address Fax Number:
918-488-6609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6606 S YALE AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74136-3364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-488-6608
Provider Business Practice Location Address Fax Number:
918-488-6609
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARRETT
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-488-6608

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  17128 , 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: 200311360A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: DQ7156 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 442624408002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 0004116209 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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