Healthcare Provider Details

I. General information

NPI: 1548218803
Provider Name (Legal Business Name): DAVID BRENT ROTTON DO, FACOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E. DOWNING #103
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 1008
TAHLEQUAH OK
74465-1008
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-1140
  • Fax: 918-207-0335
Mailing address:
  • Phone: 918-207-1410
  • Fax: 918-207-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number118997
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3315
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier020043303
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICARE RAILROAD
# 2
Identifier244688909
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 3
IdentifierCF9170
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICARE RAILROAD
# 4
Identifier100102820A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: