Basic Information
| Provider Information | |||||||||
| NPI: | 1023063997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADA FAMILY MEDICAL CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803109510 | ||||||||
| FaxNumber: | 5804364447 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803109510 | ||||||||
| FaxNumber: | 5804364447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | JASON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5803109510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3540 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.