Provider Demographics
NPI:1477899532
Name:MEDICINE WHEEL INC
Entity Type:Organization
Organization Name:MEDICINE WHEEL INC
Other - Org Name:CADDO FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEATHERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-367-2100
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:CADDO
Mailing Address - State:OK
Mailing Address - Zip Code:74729-0146
Mailing Address - Country:US
Mailing Address - Phone:580-367-2100
Mailing Address - Fax:580-367-2103
Practice Address - Street 1:128 BUFFALO STREET
Practice Address - Street 2:
Practice Address - City:CADDO
Practice Address - State:OK
Practice Address - Zip Code:74729
Practice Address - Country:US
Practice Address - Phone:580-367-2100
Practice Address - Fax:580-367-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2982207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200328450AMedicaid
OK200328450BMedicaid
OKOKAAA1268Medicare PIN