Basic Information
| Provider Information | |||||||||
| NPI: | 1902836901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRITTENDEN | ||||||||
| FirstName: | MICKEY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #140 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523162 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 E MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731311253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053417009 | ||||||||
| FaxNumber: | 4053401817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
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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 | 208000000X | 11345 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 15429 | 01 | OK | OBNDD | OTHER | 100110500B | 05 | OK | MEDICAID | 11345 | 01 | OK | LICENSE | OTHER |