Healthcare Provider Details

I. General information

NPI: 1376624361
Provider Name (Legal Business Name): MICHAEL D DAVID DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 HIGHWAY 59 N
GROVE OK
74344-4229
US

IV. Provider business mailing address

PO BOX 451087
GROVE OK
74345-1087
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-5026
  • Fax: 918-786-5141
Mailing address:
  • Phone: 918-786-5026
  • Fax: 918-786-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3714
License Number StateOK

VIII. Authorized Official

Name: MICHAEL D DAVID
Title or Position: OWNER
Credential: DO
Phone: 918-786-5026