Healthcare Provider Details

I. General information

NPI: 1407769243
Provider Name (Legal Business Name): GENESIS MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5370 NW CACHE RD STE 1
LAWTON OK
73505-3371
US

IV. Provider business mailing address

5370 NW CACHE RD STE 1
LAWTON OK
73505-3371
US

V. Phone/Fax

Practice location:
  • Phone: 580-221-2022
  • Fax:
Mailing address:
  • Phone: 580-221-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHERRY LYNNE CLARK
Title or Position: BILLING/CREDENTIALING
Credential:
Phone: 580-223-5180