Provider Demographics
NPI:1528408523
Name:ALTUS PREMIER HEALTH CLINIC P.L.L.C.
Entity Type:Organization
Organization Name:ALTUS PREMIER HEALTH CLINIC P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDALLAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAWOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-379-6550
Mailing Address - Street 1:304 S PARK LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5753
Mailing Address - Country:US
Mailing Address - Phone:580-379-6550
Mailing Address - Fax:580-379-6559
Practice Address - Street 1:304 S PARK LN STE B
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5754
Practice Address - Country:US
Practice Address - Phone:580-379-6550
Practice Address - Fax:580-379-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24330305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200053860BMedicaid
OK200527450AMedicaid