Provider Demographics
NPI:1073503934
Name:CHICHESTER, CAROLYN J
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:CHICHESTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12385 N PUMPKIN HOLW
Mailing Address - Street 2:
Mailing Address - City:PROCTOR
Mailing Address - State:OK
Mailing Address - Zip Code:74457-3219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RR 6 BOX 840
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-8703
Practice Address - Country:US
Practice Address - Phone:918-696-8834
Practice Address - Fax:918-696-8897
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK127642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE42484Medicare UPIN