Provider Demographics
NPI:1164042560
Name:HIGGANBOTHAM, CLARK R
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:R
Last Name:HIGGANBOTHAM
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 1:1701 BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLS HILLS
Mailing Address - State:OK
Mailing Address - Zip Code:73116-5301
Mailing Address - Country:US
Mailing Address - Phone:405-625-4063
Mailing Address - Fax:
Practice Address - Street 1:800 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program