Healthcare Provider Details

I. General information

NPI: 1114920071
Provider Name (Legal Business Name): BOB R ABERNATHY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N GLENN ENGLISH
CORDELL OK
73632-2010
US

IV. Provider business mailing address

1220 N GLENN L ENGLISH ST
CORDELL OK
73632-2010
US

V. Phone/Fax

Practice location:
  • Phone: 580-832-3838
  • Fax: 580-832-5119
Mailing address:
  • Phone: 580-832-3339
  • Fax: 580-832-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2075
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: