Basic Information
Provider Information | |||||||||
NPI: | 1194937904 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL OK FAMILY MED CTR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COFMC NOBLE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 358 | ||||||||
Address2: | 527 W 3RD ST | ||||||||
City: | KONAWA | ||||||||
State: | OK | ||||||||
PostalCode: | 74849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809252362 | ||||||||
Practice Location | |||||||||
Address1: | 303 72ND SE | ||||||||
Address2: |   | ||||||||
City: | NOBLE | ||||||||
State: | OK | ||||||||
PostalCode: | 73068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058721270 | ||||||||
FaxNumber: | 4058721269 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 10/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHARP | ||||||||
AuthorizedOfficialFirstName: | DENISE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
AuthorizedOfficialTelephone: | 5809253286 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL OKLAHOOMA FAMILY MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | AR,NP. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 100737160D | 05 | OK |   | MEDICAID |