Basic Information
| Provider Information | |||||||||
| NPI: | 1780610717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBRIEN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056924777 | ||||||||
| FaxNumber: | 4056924778 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 N FINDLAY AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053104300 | ||||||||
| FaxNumber: | 4053104311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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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 | 21262 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100256060 | 05 | OK | MEDICAID |