Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 170100000X | Medical Geneticist | 22563 | OK |
NPI | 1205941762 |
---|---|
Provider Name | Dr. Robert Miles Chisholm III |
First Address | Lawton, OK 73501-3727 |
Second Address | Lawton, OK 73501-3727 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 10/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
080185221 | RAILROAD MEDICARE (01) | |
100108500B | (05) | OK |
H59329 | (02) | OK |