Healthcare Provider Details

I. General information

NPI: 1063894467
Provider Name (Legal Business Name): KATELIN ELISE THAI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 1ST ST
ALTUS AFB OK
73523-5004
US

IV. Provider business mailing address

301 N 1ST ST
ALTUS AFB OK
73523-5004
US

V. Phone/Fax

Practice location:
  • Phone: 580-481-5433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number6102
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number2022-00893
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: