Healthcare Provider Details

I. General information

NPI: 1922149426
Provider Name (Legal Business Name): EDGAR L LECLAIRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4509 INTEGRIS PKWY STE 300
EDMOND OK
73034-8696
US

IV. Provider business mailing address

3001 QUAIL SPRINGS PKWY FL 5
OKLAHOMA CITY OK
73134-2640
US

V. Phone/Fax

Practice location:
  • Phone: 405-657-3704
  • Fax: 405-657-3892
Mailing address:
  • Phone: 405-657-3704
  • Fax: 405-657-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24774
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number24774
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: