Provider Demographics
NPI:1003892621
Name:ENGLESTEAD, BRADY GENE (MD)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:GENE
Last Name:ENGLESTEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3963 S. HIGHWAY 97 #113
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063
Mailing Address - Country:US
Mailing Address - Phone:918-762-6536
Mailing Address - Fax:918-762-4614
Practice Address - Street 1:1201 HERITAGE CIRCLE
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058
Practice Address - Country:US
Practice Address - Phone:918-762-6536
Practice Address - Fax:918-762-4614
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG61255Medicare UPIN