Healthcare Provider Details

I. General information

NPI: 1760498745
Provider Name (Legal Business Name): MARY C CARLILE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

IV. Provider business mailing address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-2404
  • Fax: 918-458-2405
Mailing address:
  • Phone: 918-458-2404
  • Fax: 918-458-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number28123
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier41590
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOKLAHOMA BUREAU OF NARCOTICS
# 2
Identifier28123
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOKLAHOMA MEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: