Provider Demographics
NPI:1518977628
Name:MENZ, GEORGE DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DOUGLAS
Last Name:MENZ
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 1:20912 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-6439
Mailing Address - Country:US
Mailing Address - Phone:405-391-2970
Mailing Address - Fax:405-391-2972
Practice Address - Street 1:20912 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-6439
Practice Address - Country:US
Practice Address - Phone:405-391-2970
Practice Address - Fax:405-391-2972
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG73438Medicare UPIN
OK800522008Medicare ID - Type Unspecified