Provider Demographics
NPI:1285852947
Name:CHAUNCEY B WITCRAFT MD PC
Entity Type:Organization
Organization Name:CHAUNCEY B WITCRAFT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAUNCEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WITCRAFT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:918-542-2812
Mailing Address - Street 1:310 2ND AVE SW STE 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6708
Mailing Address - Country:US
Mailing Address - Phone:918-542-2812
Mailing Address - Fax:918-542-2814
Practice Address - Street 1:310 2ND AVE SW STE 105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6708
Practice Address - Country:US
Practice Address - Phone:918-542-2812
Practice Address - Fax:918-542-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13131261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK363287549002OtherBLUE CROSS BLUE SHIELD-OK