Healthcare Provider Details

I. General information

NPI: 1427021450
Provider Name (Legal Business Name): KENNETH TED DARVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W MACARTHUR ST
SHAWNEE OK
74804-1743
US

IV. Provider business mailing address

1102 W MACARTHUR ST
SHAWNEE OK
74804-1743
US

V. Phone/Fax

Practice location:
  • Phone: 405-878-8110
  • Fax: 405-878-8101
Mailing address:
  • Phone: 405-878-8110
  • Fax: 405-878-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20274
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: