Basic Information
| Provider Information | |||||||||
| NPI: | 1104879410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEITER | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SW 89TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056327256 | ||||||||
| FaxNumber: | 4056026420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 SW 89TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056327256 | ||||||||
| FaxNumber: | 4056026420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2310 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100194840A | 05 | OK | MEDICAID |