Healthcare Provider Details

I. General information

NPI: 1518014729
Provider Name (Legal Business Name): JOHN C FRIEDL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E RAY FINE BLVD SUITE 6
ROLAND OK
74954-5380
US

IV. Provider business mailing address

12605 S ELWOOD AVE
JENKS OK
74037-2814
US

V. Phone/Fax

Practice location:
  • Phone: 918-503-6235
  • Fax: 918-398-0637
Mailing address:
  • Phone: 918-296-0654
  • Fax: 918-398-0637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberN-8164
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberN-8164
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberN-8164
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: