Provider Demographics
NPI:1053316786
Name:GROOMS, GUY ERIC (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:ERIC
Last Name:GROOMS
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 1:209 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5043
Mailing Address - Country:US
Mailing Address - Phone:918-682-7717
Mailing Address - Fax:918-682-9434
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20183174400000X
IDM-13759207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100213780AMedicaid
OK100213780AMedicaid
OKF03950Medicare UPIN