Basic Information
| Provider Information | |||||||||
| NPI: | 1548205214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWBERRY | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #140 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523162 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 N ROCKWELL AVE | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730085246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057554050 | ||||||||
| FaxNumber: | 4057521553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
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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 | 207Q00000X | 11240 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100110540B | 05 | OK | MEDICAID | 11240 | 01 | OK | LICENSE | OTHER | 080156332 | 01 | OK | RAILROAD | OTHER | 15648 | 01 | OK | OBNDD | OTHER |