Provider Demographics
NPI:1518132885
Name:FOOT AND ANKLE CLINIC OF WESTERN OKLAHOMA
Entity Type:Organization
Organization Name:FOOT AND ANKLE CLINIC OF WESTERN OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:580-323-5800
Mailing Address - Street 1:800 FRISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3306
Mailing Address - Country:US
Mailing Address - Phone:580-323-5800
Mailing Address - Fax:580-323-5802
Practice Address - Street 1:1221 COLORADO AVE
Practice Address - Street 2:STE C
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-2800
Practice Address - Country:US
Practice Address - Phone:580-225-9955
Practice Address - Fax:580-225-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK230213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00162625OtherRAILROAD MEDICARE
OK200026900AMedicaid
OK200522085OtherMEDICARE GROUP
OK5158640002Medicare NSC
OK200026900AMedicaid
OK200522085OtherMEDICARE GROUP