Provider Demographics
NPI:1275738148
Name:DAVE, MAYANK NANDKISHOR (MD)
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:NANDKISHOR
Last Name:DAVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAYANKKUMAR
Other - Middle Name:NANDKISHOR
Other - Last Name:DAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5606 SW LEE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9688
Mailing Address - Country:US
Mailing Address - Phone:580-536-5300
Mailing Address - Fax:580-536-5304
Practice Address - Street 1:5606 SW LEE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9688
Practice Address - Country:US
Practice Address - Phone:580-536-5300
Practice Address - Fax:580-536-5304
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine