Healthcare Provider Details

I. General information

NPI: 1770504037
Provider Name (Legal Business Name): MIGUEL ANTONIO CAMACHO-GARRIDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 WALNUT DR
ARDMORE OK
73401-2353
US

IV. Provider business mailing address

1104 WALNUT DR
ARDMORE OK
73401-2353
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-0543
  • Fax: 580-226-2284
Mailing address:
  • Phone: 580-226-0543
  • Fax: 580-226-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number18653
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: