Healthcare Provider Details

I. General information

NPI: 1386669745
Provider Name (Legal Business Name): ARDRY LANCE YARBROUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 S VIRGINIA AVE
ATOKA OK
74525-3246
US

IV. Provider business mailing address

1504 S VIRGINIA AVE
ATOKA OK
74525-3246
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-4746
  • Fax: 580-889-4735
Mailing address:
  • Phone: 580-889-4746
  • Fax: 580-889-4735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22046
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: