Provider Demographics
NPI:1164418356
Name:DAVE, DEENA (MD)
Entity Type:Individual
Prefix:
First Name:DEENA
Middle Name:
Last Name:DAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 S.W 67TH STR.
Mailing Address - Street 2:SUITE 2 AND 3
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-250-0324
Mailing Address - Fax:580-248-4523
Practice Address - Street 1:1202 SW 67TH STR
Practice Address - Street 2:SUITE 2 AND 3
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-250-0324
Practice Address - Fax:580-248-4523
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100084210AMedicaid
OK100084210AMedicaid