Basic Information
Provider Information | |||||||||
NPI: | 1740207828 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN OKLAHOMA RADIOLOGY PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1589 | ||||||||
Address2: |   | ||||||||
City: | ELK CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 736481589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802255406 | ||||||||
FaxNumber: | 5802255423 | ||||||||
Practice Location | |||||||||
Address1: | 520 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | GUYMON | ||||||||
State: | OK | ||||||||
PostalCode: | 739424438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5803386515 | ||||||||
FaxNumber: | 5802255423 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
AuthorizedOfficialTelephone: | 5802255403 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.