Healthcare Provider Details

I. General information

NPI: 1700690690
Provider Name (Legal Business Name): EDWARD DEAN HULBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 N UNION ST
PONCA CITY OK
74601-2440
US

IV. Provider business mailing address

PO BOX 182
PONCA CITY OK
74602-0182
US

V. Phone/Fax

Practice location:
  • Phone: 580-686-0202
  • Fax:
Mailing address:
  • Phone: 580-686-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: