1942598628 NPI number — ENID UROLOGY ASSOCIATES, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942598628 NPI number — ENID UROLOGY ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENID UROLOGY ASSOCIATES, 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:
1942598628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 E OKLAHOMA AVE
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73701-5951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-233-3230
Provider Business Mailing Address Fax Number:
580-233-0698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 VIRGINIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONCA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74601-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-233-3230
Provider Business Practice Location Address Fax Number:
580-233-0698
Provider Enumeration Date:
07/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDS
Authorized Official First Name:
TROY
Authorized Official Middle Name:
ALBERT
Authorized Official Title or Position:
MANAGING/TREATING PHYSICIAN
Authorized Official Telephone Number:
580-233-3230

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , 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: 24087 . This is a "STATE LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 32898 . This is a "OBNDD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200037540A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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