Basic Information
| Provider Information | |||||||||
| NPI: | 1497743405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHENER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | LEWIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 W GORE BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803572261 | ||||||||
| FaxNumber: | 5803572263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 19658 | OK | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0915990004 | 01 | OK | MEDICARE PTAN | OTHER | P00263322 | 01 | OK | RAILROAD MEDICARE | OTHER | 100137220A | 05 | OK | MEDICAID |