Provider Demographics
NPI:1235107814
Name:AMIGO, THERESE MB (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESE
Middle Name:MB
Last Name:AMIGO
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Gender:F
Credentials:MD
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Mailing Address - Street 1:350 S 40TH ST
Mailing Address - Street 2:CCOM MEDICAL GROUP, INC.
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4915
Mailing Address - Country:US
Mailing Address - Phone:918-683-0753
Mailing Address - Fax:918-687-5251
Practice Address - Street 1:401 S YORK ST
Practice Address - Street 2:CCOM MEDICAL GROUP, INC.
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-5955
Practice Address - Country:US
Practice Address - Phone:918-683-1144
Practice Address - Fax:918-683-5316
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
OK21291208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG99762Medicare UPIN