Healthcare Provider Details

I. General information

NPI: 1740514306
Provider Name (Legal Business Name): AMANDA RUTH GORDEN GREEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

IV. Provider business mailing address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

V. Phone/Fax

Practice location:
  • Phone: 918-535-6000
  • Fax: 918-535-2694
Mailing address:
  • Phone: 918-535-6000
  • Fax: 918-535-2694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4906
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: