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General NPI Number Information
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NPI Number | 1790839900
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Entity Type | Organization
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Legal Business Name | STILLWATER SKIN & CANCER MEDICAL CLINIC, INC
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1604 W 8TH AVE
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City | STILLWATER
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State | OK
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Zip | 74074-4207
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Country | US
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Telephone | 405-624-1077
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Fax | 405-377-2273
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Provider Business Mailing Address
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Address Line | PO BOX 108809
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City | OKLAHOMA CITY
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State | OK
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Zip | 73101-8809
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Country | US
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Telephone | 405-624-1077
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Fax | 405-377-2273
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT A BREEDLOVE
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Credential | M.D., F.A.AD.
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Telephone | 405-624-1077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 10612
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License Number State | OK
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