Provider Demographics
NPI:1114920071
Name:ABERNATHY, BOB R (DO)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:R
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1220 N GLENN L ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELL
Mailing Address - State:OK
Mailing Address - Zip Code:73632-2010
Mailing Address - Country:US
Mailing Address - Phone:580-832-3339
Mailing Address - Fax:580-832-5076
Practice Address - Street 1:1200 N GLENN ENGLISH
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-2010
Practice Address - Country:US
Practice Address - Phone:580-832-3838
Practice Address - Fax:580-832-5119
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2016-07-18
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Provider Licenses
StateLicense IDTaxonomies
OK2075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101100AMedicaid
OK100101100COtherSOONERCARE CHOICE
OK125307900OtherDOL
08013806OtherRAILROAD MC
OK321802700OtherDEPARTMENT OF LABOR
OK$$$$$$$$$Medicare PIN
OK321802700OtherDEPARTMENT OF LABOR