Provider Demographics
NPI:1114288958
Name:CRAIG, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:CRAIG
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:RR 1 BOX 70-2
Mailing Address - Street 2:
Mailing Address - City:GORE
Mailing Address - State:OK
Mailing Address - Zip Code:74435-9524
Mailing Address - Country:US
Mailing Address - Phone:918-348-4714
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 70-2
Practice Address - Street 2:
Practice Address - City:GORE
Practice Address - State:OK
Practice Address - Zip Code:74435-9524
Practice Address - Country:US
Practice Address - Phone:918-348-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305190BMedicaid