Basic Information
Provider Information | |||||||||
NPI: | 1326087818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HADDAD | ||||||||
FirstName: | PHILLIP | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 849 | ||||||||
Address2: |   | ||||||||
City: | SHAWNEE | ||||||||
State: | OK | ||||||||
PostalCode: | 748020849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052735801 | ||||||||
FaxNumber: | 4058783814 | ||||||||
Practice Location | |||||||||
Address1: | 3315 KETHLEY RD | ||||||||
Address2: |   | ||||||||
City: | SHAWNEE | ||||||||
State: | OK | ||||||||
PostalCode: | 748049638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052735801 | ||||||||
FaxNumber: | 4058783814 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 08/29/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 17395 | OK | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 17395 | OK | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 100100070B | 05 | OK |   | MEDICAID |