Provider Demographics
NPI:1235102146
Name:KORGAN, DWIGHT JULIUS (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:JULIUS
Last Name:KORGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N FLORENCE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3159
Mailing Address - Country:US
Mailing Address - Phone:918-341-1044
Mailing Address - Fax:918-341-7443
Practice Address - Street 1:1408 N FLORENCE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3159
Practice Address - Country:US
Practice Address - Phone:918-341-1044
Practice Address - Fax:918-341-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100069Z80AMedicaid
OK100069Z80AMedicaid