Basic Information
| Provider Information | |||||||||
| NPI: | 1811007958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAFFEE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 NW 63RD ST | ||||||||
| Address2: | STE 208 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056084308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3705 NW 63RD ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056084308 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3454 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200056430A | 05 | OK | MEDICAID | 200056430B | 05 | OK | MEDICAID | 174330401 | 05 | TX | MEDICAID |