Basic Information
| Provider Information | |||||||||
| NPI: | 1659394765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANZEN | ||||||||
| FirstName: | DWAYNE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D. O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809771910 | ||||||||
| FaxNumber: | 5802371925 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 E GARRIOTT RD STE A | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737016153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809771910 | ||||||||
| FaxNumber: | 5802371925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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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 | 34426 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1639 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100252020C | 05 | OK | MEDICAID |