Healthcare Provider Details

I. General information

NPI: 1619966108
Provider Name (Legal Business Name): MICHAEL DAVID RADER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W 3RD ST
ELK CITY OK
73644-5103
US

IV. Provider business mailing address

1121 W 3RD ST
ELK CITY OK
73644-5103
US

V. Phone/Fax

Practice location:
  • Phone: 580-243-3376
  • Fax: 580-243-3377
Mailing address:
  • Phone: 580-243-3376
  • Fax: 580-243-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number18832
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number18832
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number18832
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: