Basic Information
| Provider Information | |||||||||
| NPI: | 1649485996 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL OK FAMILY MED CTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COFMC KONAWA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 358 | ||||||||
| Address2: | 527 W 3RD ST | ||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHARP | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CE.O. | ||||||||
| AuthorizedOfficialTelephone: | 5809253286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ARNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100737160D | 05 | OK | MEDICAID |