Healthcare Provider Details

I. General information

NPI: 1497743405
Provider Name (Legal Business Name): SCOTT LEWIS MICHENER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W GORE BLVD SUITE 201
LAWTON OK
73505
US

IV. Provider business mailing address

PO BOX 785
LAWTON OK
73502
US

V. Phone/Fax

Practice location:
  • Phone: 580-357-2261
  • Fax: 580-357-2263
Mailing address:
  • Phone: 580-357-9984
  • Fax: 580-357-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number19658
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: