Basic Information
| Provider Information | |||||||||
| NPI: | 1548365117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269064 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313857 | ||||||||
| FaxNumber: | 4052727977 | ||||||||
| Practice Location | |||||||||
| Address1: | 6908 E RENO AVE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731102128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057377000 | ||||||||
| FaxNumber: | 4057377700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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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 | 03095 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207PE0004X | 3095 | OK | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 200102570A | 05 | OK | MEDICAID | 73-0804209 | 01 | OK | TAX ID | OTHER | 730804209001 | 01 | OK | BC GROUP NUMBER | OTHER |