Healthcare Provider Details

I. General information

NPI: 1700105236
Provider Name (Legal Business Name): TRAVIS CLARK GARRETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W MEMORIAL RD
OKLAHOMA CITY OK
73120-8304
US

IV. Provider business mailing address

4200 W MEMORIAL RD STE 610
OKLAHOMA CITY OK
73120-9350
US

V. Phone/Fax

Practice location:
  • Phone: 405-752-3962
  • Fax: 405-752-3963
Mailing address:
  • Phone: 405-752-3962
  • Fax: 405-752-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number29881
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29881
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number550206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: