Provider Demographics
NPI:1407979131
Name:STILLWATER SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:STILLWATER SPORTS MEDICINE, INC.
Other - Org Name:STILLWATER ORTHOPEDIC AND SPORTS MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-707-7500
Mailing Address - Street 1:320 N PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-5513
Mailing Address - Country:US
Mailing Address - Phone:405-707-7500
Mailing Address - Fax:405-707-9948
Practice Address - Street 1:320 N PERKINS RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-5513
Practice Address - Country:US
Practice Address - Phone:405-707-7500
Practice Address - Fax:405-707-9948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty