Basic Information
| Provider Information | |||||||||
| NPI: | 1841384021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLGREN | ||||||||
| FirstName: | WELDON | ||||||||
| MiddleName: | JOHN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 W DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | NOWATA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740482601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183429530 | ||||||||
| FaxNumber: | 9183426852 | ||||||||
| Practice Location | |||||||||
| Address1: | 17599 S HIGHWAY 88 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740170801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183429530 | ||||||||
| FaxNumber: | 9183429533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 2084P0800X | 2466 | OK | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 100227390C | 05 | OK | MEDICAID |