Basic Information
Provider Information | |||||||||
NPI: | 1881682888 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | HAWKINS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 541 S LAHOMA AVE | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730695525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052021616 | ||||||||
FaxNumber: | 4053601309 | ||||||||
Practice Location | |||||||||
Address1: | 5920 MCINTYRE ST | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 80403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7204344876 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2005 | ||||||||
LastUpdateDate: | 09/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 14739 | OK | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | DR.0059468 | CO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 610405700 | 01 | OK | DEPT OF LABOR | OTHER | 100130130A | 05 | OK |   | MEDICAID |