Provider Demographics
NPI:1467487132
Name:STILLWATER DERMATOLOGY CLINIC
Entity Type:Organization
Organization Name:STILLWATER DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-533-3376
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74076-1500
Mailing Address - Country:US
Mailing Address - Phone:405-533-3376
Mailing Address - Fax:405-533-2642
Practice Address - Street 1:1329 S SANGRE RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1854
Practice Address - Country:US
Practice Address - Phone:405-533-3376
Practice Address - Fax:405-533-2642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22869207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522536Medicare PIN
OKI34760Medicare UPIN