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General NPI Number Information
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NPI Number | 1285852947
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Entity Type | Organization
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Legal Business Name | CHAUNCEY B WITCRAFT MD PC
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 10/04/2007
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Provider Practice Location Address
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Address Line | 310 2ND AVE SW STE 105
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City | MIAMI
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State | OK
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Zip | 74354-6708
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Country | US
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Telephone | 918-542-2812
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Fax | 918-542-2814
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Provider Business Mailing Address
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Address Line | 310 2ND AVE SW STE 105
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City | MIAMI
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State | OK
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Zip | 74354-6708
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Country | US
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Telephone | 918-542-2812
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Fax | 918-542-2814
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHAUNCEY B WITCRAFT III
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Credential | MD
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Telephone | 918-542-2812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 13131
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License Number State | OK
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