Healthcare Provider Details

I. General information

NPI: 1760240501
Provider Name (Legal Business Name): OK MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 10/28/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 NW 135TH STREET
OKLAHOMA CITY OK
73120-4009
US

IV. Provider business mailing address

3410 NW 135TH STREET
OKLAHOMA CITY OK
73120-4009
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-6111
  • Fax: 405-751-0479
Mailing address:
  • Phone: 405-751-6111
  • Fax: 405-751-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WALTER SCOTT WAUGH
Title or Position: PHYSICIAN
Credential: MD
Phone: 405-227-4909