Healthcare Provider Details

I. General information

NPI: 1083766703
Provider Name (Legal Business Name): DEARBORN EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST DONALD W REYNOLDS DEPT. GERIATRIC MEDICINE (VAMC 11G)
OKLAHOMA CITY OK
73104
US

IV. Provider business mailing address

PO BOX 1306
SEMINOLE OK
74818-1306
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8558
  • Fax: 405-271-3887
Mailing address:
  • Phone: 405-303-2518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number23381
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: