Healthcare Provider Details

I. General information

NPI: 1578358214
Provider Name (Legal Business Name): CHARLES PAUL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1973 W 33RD ST STE 110
EDMOND OK
73013-3875
US

IV. Provider business mailing address

1973 W 33RD ST STE 110
EDMOND OK
73013-3875
US

V. Phone/Fax

Practice location:
  • Phone: 918-706-3947
  • Fax:
Mailing address:
  • Phone: 918-706-3947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License NumberULC600728
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: