Provider Demographics
NPI:1497791578
Name:MCCAULEY, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MCCAULEY
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 1:2410 N COMMERCE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401
Mailing Address - Country:US
Mailing Address - Phone:580-276-0812
Mailing Address - Fax:580-226-0820
Practice Address - Street 1:2410 N COMMERCE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-276-0812
Practice Address - Fax:580-226-0820
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13050207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100163880AMedicaid
OK100163880AMedicaid
D35006Medicare UPIN