Basic Information
| Provider Information | |||||||||
| NPI: | 1245762293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETTEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 MERCHANT DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730696470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058098713 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10740 S MAY AVE STE 111 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052869605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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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 | 225100000X | 43156 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 4958 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.