Provider Demographics
NPI:1295840288
Name:PHELPS, CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:PHELPS
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:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-1047
Mailing Address - Country:US
Mailing Address - Phone:580-225-8600
Mailing Address - Fax:580-225-8603
Practice Address - Street 1:1710 W 3RD ST
Practice Address - Street 2:SUITE 103B
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5159
Practice Address - Country:US
Practice Address - Phone:580-225-8600
Practice Address - Fax:580-225-8603
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100200430AMedicaid
OKP00343048OtherRR MEDICARE
OKD35131Medicare UPIN
OK5154668520RMedicare ID - Type Unspecified