Provider Demographics
NPI:1093847394
Name:MONTY J GRUGAN DO PC
Entity Type:Organization
Organization Name:MONTY J GRUGAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-584-3242
Mailing Address - Street 1:117 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3933
Mailing Address - Country:US
Mailing Address - Phone:580-584-3246
Mailing Address - Fax:
Practice Address - Street 1:117 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3933
Practice Address - Country:US
Practice Address - Phone:580-584-3246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH83968Medicare UPIN