=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376624361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL D DAVID DO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4602 HIGHWAY 59 N
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344-4229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-5026
-----------------------------------------------------
Fax | 918-786-5141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 451087
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74345-1087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-5026
-----------------------------------------------------
Fax | 918-786-5141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL D DAVID
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 918-786-5026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3714
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------