Basic Information
| Provider Information | |||||||||
| NPI: | 1275698862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 S 28TH ST | ||||||||
| Address2: | APT # B-3 | ||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736013609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803232884 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 1 BOX 3060 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736019303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803232884 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 208000000X | 35050525E | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 9135050 | 05 | OK | MEDICAID |