Healthcare Provider Details

I. General information

NPI: 1700880127
Provider Name (Legal Business Name): BRENDA R. STUTZMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 N BROADWAY AVE
HYDRO OK
73048-8425
US

IV. Provider business mailing address

579 N BROADWAY AVE
HYDRO OK
73048-8425
US

V. Phone/Fax

Practice location:
  • Phone: 405-663-2291
  • Fax: 405-663-2191
Mailing address:
  • Phone: 405-663-2291
  • Fax: 405-663-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3099
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: