Healthcare Provider Details

I. General information

NPI: 1669977856
Provider Name (Legal Business Name): ELIZABETH ANNE EAGLE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH ANNE FORNER DO

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

3500 GASTON AVE
DALLAS TX
75246-2017
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number7559
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: