Healthcare Provider Details

I. General information

NPI: 1275504649
Provider Name (Legal Business Name): WILLIAM M LYTKOWSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 WALNUT DR
ARDMORE OK
73401-2354
US

IV. Provider business mailing address

1103 WALNUT DR
ARDMORE OK
73401-2354
US

V. Phone/Fax

Practice location:
  • Phone: 580-504-3999
  • Fax:
Mailing address:
  • Phone: 580-504-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4530
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: