Basic Information
| Provider Information | |||||||||
| NPI: | 1558623934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENOWETH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 STANTON L YOUNG BLVD # 3400 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052714426 | ||||||||
| FaxNumber: | 4052713461 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 NE 10TH ST # 1C | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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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 | 207X00000X | 29364 | OK | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MT212690 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | MT212690 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 29364 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200313730A | 05 | OK | MEDICAID | 200445850A | 05 | OK | MEDICAID |