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NPI Code Detail

MEDICARE: ANTHONY DIRTEATER

MEDICARE: ANTHONY DIRTEATER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1175T00000XPeer Specialist

General Provider Information

NPI Number : 1265202659
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANTHONY DIRTEATER
Provider Business Mailing Address
First Line : 113 W KEETOOWAH ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3819
Country : US
Telephone Number : 918-931-3700
Fax Number :
Provider Business Practice Location Address
First Line : 113 W KEETOOWAH ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3819
Country : US
Telephone Number : 918-931-3700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/05/2024
Last Update Date : 01/05/2024

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Directions to “ ANTHONY DIRTEATER ” Practice Location

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