Healthcare Provider Details

I. General information

NPI: 1770567554
Provider Name (Legal Business Name): DAN RAYMOND NORTHEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 S WESTERN AVE
OKLAHOMA CITY OK
73109-3410
US

IV. Provider business mailing address

4201 S WESTERN AVE
OKLAHOMA CITY OK
73109-3410
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-4000
  • Fax: 405-632-4073
Mailing address:
  • Phone: 405-632-4000
  • Fax: 405-632-4073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number10600
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: