Provider Demographics
NPI:1336321884
Name:ENGELSGJERD, MICHAEL REUBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:REUBEN
Last Name:ENGELSGJERD
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 1:715 SOUTH 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750
Mailing Address - Country:US
Mailing Address - Phone:580-614-2000
Mailing Address - Fax:580-614-2070
Practice Address - Street 1:715 S 8TH ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-3513
Practice Address - Country:US
Practice Address - Phone:580-614-2000
Practice Address - Fax:580-614-2070
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26010208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE52390Medicare UPIN