Basic Information
| Provider Information | |||||||||
| NPI: | 1386932333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOOD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2492 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730832492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076699 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1008 NW 139TH STREET PKWY | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730139791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076699 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 52493 | TN | Y |
ID Information
| ID | Type | State | Issuer | Description | 200814060A | 05 | OK | MEDICAID |