Basic Information
Provider Information | |||||||||
NPI: | 1306818828 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | HAMPTON | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 306 CAMPBELL ST | ||||||||
Address2: |   | ||||||||
City: | BROKEN BOW | ||||||||
State: | OK | ||||||||
PostalCode: | 747283142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5805843835 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 902 E LINCOLN RD | ||||||||
Address2: |   | ||||||||
City: | IDABEL | ||||||||
State: | OK | ||||||||
PostalCode: | 747457337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802862600 | ||||||||
FaxNumber: | 5802861189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 05-24017 | KS | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | BA2064272 | 01 |   | DEA | OTHER | 8EZ13T | 05 | OK |   | MEDICAID |