Healthcare Provider Details

I. General information

NPI: 1275983777
Provider Name (Legal Business Name): MILLARD LAFAYETTE HENRY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 S DOUGLAS AVE STE 200
OKLAHOMA CITY OK
73109-3215
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-636-7499
  • Fax: 405-636-7809
Mailing address:
  • Phone: 405-636-7499
  • Fax: 405-636-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number32424
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: