Provider Demographics
NPI:1093084352
Name:WEBBER, DEREK ETHAN
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ETHAN
Last Name:WEBBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 S MIDWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4642
Mailing Address - Country:US
Mailing Address - Phone:405-733-5437
Mailing Address - Fax:405-732-7741
Practice Address - Street 1:316 S MIDWEST BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4642
Practice Address - Country:US
Practice Address - Phone:405-733-5437
Practice Address - Fax:405-732-7741
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator