Healthcare Provider Details

I. General information

NPI: 1275698862
Provider Name (Legal Business Name): KENNETH M EGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 3060
CLINTON OK
73601-9303
US

IV. Provider business mailing address

215 S 28TH ST APT # B-3
CLINTON OK
73601-3609
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-2884
  • Fax: 580-323-2579
Mailing address:
  • Phone: 580-323-2884
  • Fax: 580-323-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35050525E
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: