Provider Demographics
NPI:1528204567
Name:WEATHERFORD FAMILY PRACTICE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:WEATHERFORD FAMILY PRACTICE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:ROCHELLE
Authorized Official - Last Name:MALLETT MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-772-2400
Mailing Address - Street 1:3739 LEGACY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-9746
Mailing Address - Country:US
Mailing Address - Phone:580-772-2400
Mailing Address - Fax:580-772-2408
Practice Address - Street 1:3739 LEGACY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-9746
Practice Address - Country:US
Practice Address - Phone:580-772-2400
Practice Address - Fax:580-772-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00691960OtherRAIL ROAD MEDICARE PTAN
OK200224110AMedicaid
OK26755OtherOKLAHOMA STATE MEDICAL LICENSE
OK37994OtherBNDD
OKOKB5382OtherMEDICARE PTAN
OK26755OtherOKLAHOMA STATE MEDICAL LICENSE