Basic Information
| Provider Information | |||||||||
| NPI: | 1003859679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12697 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741466236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185053200 | ||||||||
| FaxNumber: | 9185053253 | ||||||||
| Practice Location | |||||||||
| Address1: | 12697 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741466236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185053200 | ||||||||
| FaxNumber: | 9185053253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 05/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 14470 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 15268 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 331740YV6N | 01 | OK | MEDICARE PTAN | OTHER |