Basic Information
| Provider Information | |||||||||
| NPI: | 1114920071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABERNATHY | ||||||||
| FirstName: | BOB | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 N GLENN L ENGLISH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5808323339 | ||||||||
| FaxNumber: | 5808325076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N GLENN ENGLISH | ||||||||
| Address2: | |||||||||
| City: | CORDELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5808323838 | ||||||||
| FaxNumber: | 5808325119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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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 | 207Q00000X | 2075 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100101100A | 05 | OK | MEDICAID | 100101100C | 01 | OK | SOONERCARE CHOICE | OTHER | 125307900 | 01 | OK | DOL | OTHER | 08013806 | 01 | RAILROAD MC | OTHER | 321802700 | 01 | OK | DEPARTMENT OF LABOR | OTHER |