Provider Demographics
NPI:1427196773
Name:ADA ORTHOPEDICS & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:ADA ORTHOPEDICS & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CHARBONEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-332-4443
Mailing Address - Street 1:625 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4613
Mailing Address - Country:US
Mailing Address - Phone:580-332-4443
Mailing Address - Fax:580-332-4846
Practice Address - Street 1:625 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4613
Practice Address - Country:US
Practice Address - Phone:580-332-4443
Practice Address - Fax:580-332-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDD1743OtherRAILROAD MEDICARE