Healthcare Provider Details

I. General information

NPI: 1750013652
Provider Name (Legal Business Name): MR. CORWIN JOHN ATADDLETY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. CORWIN JOHN ATADDLETY

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 N 1ST ST
ANADARKO OK
73005-2111
US

IV. Provider business mailing address

221 WICHITA DR
ANADARKO OK
73005-3705
US

V. Phone/Fax

Practice location:
  • Phone: 405-247-2428
  • Fax:
Mailing address:
  • Phone: 405-933-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: