=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467765941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYANK DAVE MDPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2010
-----------------------------------------------------
Last Update Date | 07/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5606 SW LEE BLVD STE 202
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-9689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-678-7050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5606 SW LEE BLVD STE 202
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-9689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MAYANK DAVE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-678-7050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------