{
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"NamePrefix": null,
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"FirstLineMailingAddress": "PO BOX 1109",
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"MailingAddressCityName": "SULPHUR",
"MailingAddressStateName": "OK",
"MailingAddressPostalCode": "73086-8109",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "580-622-3511",
"MailingAddressFaxNumber": "580-622-3513",
"FirstLinePracticeLocationAddress": "2007 W BROADWAY AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SULPHUR",
"PracticeLocationAddressStateName": "OK",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "580-622-3511",
"PracticeLocationAddressFaxNumber": "580-622-3513",
"EnumerationDate": "03/02/2011",
"LastUpdateDate": "10/22/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ODEN",
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"AuthorizedOfficialCredential": "DO",
"AuthorizedOfficialTelephoneNumber": "580-622-3511",
"Taxonomies": {
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"TaxonomyName": "Medical Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": "OK",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}