Provider Demographics
NPI:1326067174
Name:OHLSTROM, DOUGLAS ALLEN (MD, FACS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALLEN
Last Name:OHLSTROM
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-7200
Mailing Address - Fax:918-786-7212
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2975
Practice Address - Country:US
Practice Address - Phone:918-786-7200
Practice Address - Fax:918-786-7212
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18789208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100736700PMedicaid
OK100213060BMedicaid
OK299068YKW9Medicare PIN
OK900522214Medicare PIN
MO208013813Medicaid
P00390904Medicare PIN
A50581Medicare UPIN
OK299068YKW9Medicare PIN