Healthcare Provider Details

I. General information

NPI: 1598175309
Provider Name (Legal Business Name): STEPHN DRYWATER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 1069
TAHLEQUAH OK
74465-1069
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 184-535-7659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30727
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: