Provider Demographics
NPI:1518014729
Name:FRIEDL, JOHN C (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:FRIEDL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12605 S ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2814
Mailing Address - Country:US
Mailing Address - Phone:918-296-0654
Mailing Address - Fax:918-398-0637
Practice Address - Street 1:205 E RAY FINE BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5380
Practice Address - Country:US
Practice Address - Phone:918-503-6235
Practice Address - Fax:918-398-0637
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-8164363AM0700X, 208D00000X
OKN-8164208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
09645Medicare UPIN