Healthcare Provider Details

I. General information

NPI: 1528329208
Provider Name (Legal Business Name): MICHAEL CASSIDEY MAXTED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 405-456-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number29231
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number24810
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number29231
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number24810
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: