Healthcare Provider Details

I. General information

NPI: 1902688260
Provider Name (Legal Business Name): MR. GEORGE CLAYTON IDLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5209
US

IV. Provider business mailing address

505 SW 3RD ST
TUTTLE OK
73089-8934
US

V. Phone/Fax

Practice location:
  • Phone: 405-857-5322
  • Fax:
Mailing address:
  • Phone: 405-857-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: