Healthcare Provider Details

I. General information

NPI: 1912110578
Provider Name (Legal Business Name): DANIEL GLENN CONSTANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5606 SW LEE BOULEVARD SUITE 203
LAWTON OK
73505
US

IV. Provider business mailing address

5606 SW LEE BLVD SUITE 203
LAWTON OK
73505-0000
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-1111
  • Fax:
Mailing address:
  • Phone: 580-536-1111
  • Fax: 580-536-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301082389
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26711
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301082389
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number26711
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number4301082389
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number26711
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: