Healthcare Provider Details

I. General information

NPI: 1144104944
Provider Name (Legal Business Name): SIMON MARSHAL HYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 W 11TH ST
SHAWNEE OK
74801-6710
US

IV. Provider business mailing address

326 W 11TH ST
SHAWNEE OK
74801-6710
US

V. Phone/Fax

Practice location:
  • Phone: 405-275-3340
  • Fax:
Mailing address:
  • Phone: 405-275-3340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number22538
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: