Healthcare Provider Details

I. General information

NPI: 1457701609
Provider Name (Legal Business Name): DAVID EVANS DE GASTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SE 15TH ST STE 300
DEL CITY OK
73115-3918
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-702-9400
  • Fax: 405-702-9437
Mailing address:
  • Phone: 405-702-9400
  • Fax: 405-702-9437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32239
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: