Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 12155 | OK |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 12155 | OK |
NPI | 1043250103 |
---|---|
Provider Name | Dan F Criswell |
First Address | Duncan, OK 73533-1564 |
Second Address | Duncan, OK 73533-1572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2006 |
Last Update Date | 09/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100088900E | (05) | OK |
C94812 | (02) |