Healthcare Provider Details

I. General information

NPI: 1275759367
Provider Name (Legal Business Name): CHARLES STEPHEN PAINE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S KINGS HWY
CUSHING OK
74023-5355
US

IV. Provider business mailing address

8706 W ESECO
AGRA OK
74824-6208
US

V. Phone/Fax

Practice location:
  • Phone: 918-225-3336
  • Fax:
Mailing address:
  • Phone: 918-285-6344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036853
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number28754
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: