Healthcare Provider Details

I. General information

NPI: 1871982983
Provider Name (Legal Business Name): MIRACLE METCALF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 NE 10TH ST APT 2
OKLAHOMA CITY OK
73117-5045
US

IV. Provider business mailing address

2441 NE 10TH ST APT 2
OKLAHOMA CITY OK
73117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 405-205-4294
  • Fax:
Mailing address:
  • Phone: 405-205-4294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberL080646455
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: