Healthcare Provider Details

I. General information

NPI: 1790833481
Provider Name (Legal Business Name): CHAD P EDWARDS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12142 S YUKON AVE
GLENPOOL OK
74033
US

IV. Provider business mailing address

12142 S YUKON AVE
GLENPOOL OK
74033-6621
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3636
  • Fax: 918-296-7934
Mailing address:
  • Phone: 918-935-3636
  • Fax: 918-296-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number03124
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4353
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: