Healthcare Provider Details

I. General information

NPI: 1376588145
Provider Name (Legal Business Name): HERBERT ROSCOE LITTLETON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST STE 103
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1500 E DOWNING ST STE 103
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0001
  • Fax: 918-456-6383
Mailing address:
  • Phone: 918-456-0001
  • Fax: 918-456-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1756
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier060020996
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier100734730A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 3
Identifier731117836001
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS
# 4
Identifier100144940A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: