Healthcare Provider Details

I. General information

NPI: 1063408656
Provider Name (Legal Business Name): MITSI A FAUBION DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 STANLEY RD
CLAYTON OK
74536-0219
US

IV. Provider business mailing address

PO BOX 67
MILBURN OK
73450-0067
US

V. Phone/Fax

Practice location:
  • Phone: 918-569-4143
  • Fax: 918-569-7343
Mailing address:
  • Phone: 580-443-3533
  • Fax: 580-443-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4294
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: