Provider Demographics
NPI:1275508665
Name:OLDHAM, ANTHONY WAYNE
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:WAYNE
Last Name:OLDHAM
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 1:1267 DYER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8199
Mailing Address - Country:US
Mailing Address - Phone:231-922-8282
Mailing Address - Fax:231-922-8292
Practice Address - Street 1:1175 AIRPORT ACCESS RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3513
Practice Address - Country:US
Practice Address - Phone:231-922-8282
Practice Address - Fax:231-922-8292
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other