Provider Demographics
NPI:1376567081
Name:MAYFIELD, MARK STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STANLEY
Last Name:MAYFIELD
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 1:104 WALL ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4405
Mailing Address - Country:US
Mailing Address - Phone:918-635-3559
Mailing Address - Fax:918-635-3483
Practice Address - Street 1:104 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4405
Practice Address - Country:US
Practice Address - Phone:918-635-3555
Practice Address - Fax:918-635-3483
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4022207Q00000X
OK38659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129384706Medicaid
TX129384707Medicaid
OK201015480Medicaid
TX8A4580OtherBCBS
OK201015480AMedicaid
TX080167641OtherRR MEDICARE
TX129384708Medicaid
TX129384707Medicaid
TX8A4580OtherBCBS