Healthcare Provider Details

I. General information

NPI: 1447990296
Provider Name (Legal Business Name): MR. MARCUS CLEO BUCHANAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

IV. Provider business mailing address

PO BOX 864
CHOUTEAU OK
74337-0864
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0641
  • Fax:
Mailing address:
  • Phone: 918-864-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier000000000
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: