Basic Information
Provider Information | |||||||||
NPI: | 1760890834 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WINFREY | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3501 E GORE BLVD APT 925 | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 735016857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052013069 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3401 W GORE BLVD | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 735056332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5803558620 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2014 | ||||||||
LastUpdateDate: | 03/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0058R | OK | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 208M00000X | 5839 | OK | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 0058R | 01 | OK | OKLAHOMA RESIDENT LICENSE | OTHER |