Healthcare Provider Details

I. General information

NPI: 1952089302
Provider Name (Legal Business Name): WILLIAM KENNETH CARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 STUDENT UNION HALL
STILLWATER OK
74078-7040
US

IV. Provider business mailing address

700 W HALL OF FAME AVE
STILLWATER OK
74074
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-7714
  • Fax: 405-744-7754
Mailing address:
  • Phone: 703-587-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1264
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: