Healthcare Provider Details

I. General information

NPI: 1144295775
Provider Name (Legal Business Name): SUSAN T REDWINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N BRYANT AVE
EDMOND OK
73034-6273
US

IV. Provider business mailing address

200 N BRYANT AVE
EDMOND OK
73034-6273
US

V. Phone/Fax

Practice location:
  • Phone: 405-330-7000
  • Fax:
Mailing address:
  • Phone: 406-330-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22619
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: