Provider Demographics
NPI:1386669745
Name:YARBROUGH, ARDRY LANCE (MD)
Entity Type:Individual
Prefix:
First Name:ARDRY
Middle Name:LANCE
Last Name:YARBROUGH
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 1:1504 S VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3246
Mailing Address - Country:US
Mailing Address - Phone:580-889-4746
Mailing Address - Fax:580-889-4735
Practice Address - Street 1:1504 S VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3246
Practice Address - Country:US
Practice Address - Phone:580-889-4746
Practice Address - Fax:580-889-4735
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130780AMedicaid
H97482Medicare UPIN
OKOK402742Medicare PIN