Basic Information
| Provider Information | |||||||||
| NPI: | 1457343402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANSOLME | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | HENRI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720486 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4221 S WESTERN AVE | ||||||||
| Address2: | #4010 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056446464 | ||||||||
| FaxNumber: | 4056446465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 02/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 23723 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 200033350A | 05 | OK | MEDICAID | P00174725 | 01 | OK | RAILROAD MEDICARE | OTHER |