Healthcare Provider Details

I. General information

NPI: 1760720668
Provider Name (Legal Business Name): STILLWATER HISTOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W. 6TH ST SUITE 106
STILLWATER OK
74074
US

IV. Provider business mailing address

1301 W. 6TH ST SUITE 106
STILLWATER OK
74074
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-2390
  • Fax: 405-742-5706
Mailing address:
  • Phone: 405-372-2390
  • Fax: 405-742-5706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: THOMAS A. SWAFFORD
Title or Position: CO-OWNER
Credential: M.D.
Phone: 405-372-2390