Provider Demographics
NPI:1104846732
Name:OWENS, JOHNIE LOUIS III (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHNIE
Middle Name:LOUIS
Last Name:OWENS
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:L
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:562 S ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-6411
Mailing Address - Country:US
Mailing Address - Phone:918-824-8000
Mailing Address - Fax:918-825-5505
Practice Address - Street 1:562 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6411
Practice Address - Country:US
Practice Address - Phone:918-824-8000
Practice Address - Fax:918-825-5505
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007021791207Q00000X
OK4430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200097040AMedicaid
OK300972YLV0Medicare PIN