Healthcare Provider Details

I. General information

NPI: 1982760658
Provider Name (Legal Business Name): STEPHEN M TREADWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11053 STATE HIGHWAY 76
HEALDTON OK
73438
US

IV. Provider business mailing address

PO BOX 276
HEALDTON OK
73438-0276
US

V. Phone/Fax

Practice location:
  • Phone: 580-229-0313
  • Fax: 580-229-2045
Mailing address:
  • Phone: 580-229-0313
  • Fax: 580-229-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2909
License Number StateOK

VIII. Authorized Official

Name: STEPHEN TREADWELL
Title or Position: OWNER
Credential: DO
Phone: 580-229-0313