Healthcare Provider Details

I. General information

NPI: 1023367992
Provider Name (Legal Business Name): DUSTIN O'HERN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 S CAT CITY RD
CADDO OK
74729-5311
US

IV. Provider business mailing address

1152 S CAT CITY RD
CADDO OK
74729-5311
US

V. Phone/Fax

Practice location:
  • Phone: 918-200-2274
  • Fax:
Mailing address:
  • Phone: 918-200-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberP4359
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: