Provider Demographics
NPI:1427031863
Name:SHEEHAN, BRYAN M (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:SHEEHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452327
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-2327
Mailing Address - Country:US
Mailing Address - Phone:918-787-6893
Mailing Address - Fax:918-787-6815
Practice Address - Street 1:1200 NEO LOOP
Practice Address - Street 2:STE A
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-787-6893
Practice Address - Fax:918-787-6815
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207213E00000X
AR234213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779640AMedicaid
AR158947717Medicaid
AR5Y610Medicare PIN
OK480029473Medicare PIN
OK100779640AMedicaid
U60358Medicare UPIN
OKOK700994Medicare PIN