Healthcare Provider Details

I. General information

NPI: 1790766582
Provider Name (Legal Business Name): JUSTINE DAUTENHAHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 N PORTER AVE SUITE 100
NORMAN OK
73071-6443
US

IV. Provider business mailing address

PO BOX 1387
NORMAN OK
73070-1387
US

V. Phone/Fax

Practice location:
  • Phone: 405-364-1071
  • Fax:
Mailing address:
  • Phone: 405-321-8125
  • Fax: 405-321-8514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number13103
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: