Basic Information
| Provider Information | |||||||||
| NPI: | 1588655625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEGAZON | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NW MICKLEGATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735054164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805312448 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5602 SW LEE BLVD | ||||||||
| Address2: | SOUTHWEST MEDICAL CENTER | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735059635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805314700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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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 | 208M00000X | 30474 | OK | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | ME86566 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 267145000 | 05 | FL | MEDICAID |