1972872448 NPI number — OKLAHOMA MEDICAL PAIN MANAGEMENT

Table of content: DR. STEPHEN DAVID LANDAKER MD (NPI 1720057557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972872448 NPI number — OKLAHOMA MEDICAL PAIN MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA MEDICAL PAIN MANAGEMENT
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:
1972872448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107006 N 3600 RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADEN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74860-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-932-1234
Provider Business Mailing Address Fax Number:
405-932-1248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 SW 89TH ST STE C
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:
73139-9106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-703-8860
Provider Business Practice Location Address Fax Number:
405-900-4985
Provider Enumeration Date:
12/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MAYER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
720-219-5856

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  4354 , 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: 200080670A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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