Provider Demographics
NPI:1316039688
Name:ERICK DEROCHER D O INC
Entity Type:Organization
Organization Name:ERICK DEROCHER D O INC
Other - Org Name:FAMILY MEDICAL CLINIC OF WESTERN OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DEROCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-243-2273
Mailing Address - Street 1:411 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4127
Mailing Address - Country:US
Mailing Address - Phone:580-243-2273
Mailing Address - Fax:580-243-2832
Practice Address - Street 1:411 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4127
Practice Address - Country:US
Practice Address - Phone:580-243-2273
Practice Address - Fax:580-243-2832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200081510AMedicaid
OK200081510AMedicaid