Basic Information
Provider Information | |||||||||
NPI: | 1407979131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STILLWATER SPORTS MEDICINE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STILLWATER ORTHOPEDIC AND SPORTS MEDICINE ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 320 N PERKINS RD | ||||||||
Address2: |   | ||||||||
City: | STILLWATER | ||||||||
State: | OK | ||||||||
PostalCode: | 740755513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057077500 | ||||||||
FaxNumber: | 4057079948 | ||||||||
Practice Location | |||||||||
Address1: | 320 N PERKINS RD | ||||||||
Address2: |   | ||||||||
City: | STILLWATER | ||||||||
State: | OK | ||||||||
PostalCode: | 740755513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057077500 | ||||||||
FaxNumber: | 4057079948 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUNSON | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4057077500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.