Healthcare Provider Details

I. General information

NPI: 1417955063
Provider Name (Legal Business Name): CLINTON BRADSHAW WEBSTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 NW 63RD ST SUITE 204
OKLAHOMA CITY OK
73116-1935
US

IV. Provider business mailing address

3705 NW 63RD ST SUITE 204
OKLAHOMA CITY OK
73116-1935
US

V. Phone/Fax

Practice location:
  • Phone: 405-842-9732
  • Fax: 405-842-9771
Mailing address:
  • Phone: 405-842-9732
  • Fax: 405-842-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number362930
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number99984
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number99984
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number29518
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number29518
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: