Healthcare Provider Details

I. General information

NPI: 1861701526
Provider Name (Legal Business Name): DOCTOR'S CLINIC OF DURANT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N CHOCTAW
WAPANUCKA OK
73461
US

IV. Provider business mailing address

PO BOX 97
WAPANUCKA OK
73461-0097
US

V. Phone/Fax

Practice location:
  • Phone: 580-937-9900
  • Fax: 580-937-9935
Mailing address:
  • Phone: 580-937-9900
  • Fax: 580-937-9935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11978
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11979
License Number StateOK

VIII. Authorized Official

Name: EDIE HOWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 580-775-1656