Healthcare Provider Details

I. General information

NPI: 1689655276
Provider Name (Legal Business Name): THOMAS HAROLD CONKLIN JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
STIGLER OK
74462-2325
US

IV. Provider business mailing address

PO BOX 609
STIGLER OK
74462-0609
US

V. Phone/Fax

Practice location:
  • Phone: 918-967-2130
  • Fax: 918-967-2461
Mailing address:
  • Phone: 918-967-2130
  • Fax: 918-967-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number1552
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: