Healthcare Provider Details

I. General information

NPI: 1104819762
Provider Name (Legal Business Name): DUBOIS MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 S DOUGLAS BLVD STE D
MIDWEST CITY OK
73130-5262
US

IV. Provider business mailing address

1117 S DOUGLAS BLVD STE D
MIDWEST CITY OK
73130-5262
US

V. Phone/Fax

Practice location:
  • Phone: 405-741-8686
  • Fax: 405-733-9621
Mailing address:
  • Phone: 405-741-8686
  • Fax: 405-733-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: PEGGY CULVER DUBOIS
Title or Position: OWNER
Credential: MD
Phone: 405-741-8686