Provider Demographics
NPI:1477578862
Name:PALMER, CORLEY MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:CORLEY
Middle Name:MARK
Last Name:PALMER
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 1:930 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-3353
Mailing Address - Country:US
Mailing Address - Phone:580-763-2071
Mailing Address - Fax:
Practice Address - Street 1:900 17TH ST.
Practice Address - Street 2:WOODWARD REGIONAL HOSPITAL
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-763-2071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD35103Medicare UPIN