Healthcare Provider Details

I. General information

NPI: 1518977628
Provider Name (Legal Business Name): GEORGE DOUGLAS MENZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20912 SE 29TH ST
HARRAH OK
73045-6439
US

IV. Provider business mailing address

20912 SE 29TH ST
HARRAH OK
73045-6439
US

V. Phone/Fax

Practice location:
  • Phone: 405-391-2970
  • Fax: 405-391-2972
Mailing address:
  • Phone: 405-391-2970
  • Fax: 405-391-2972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3408
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: