Provider Demographics
NPI:1548205214
Name:DEWBERRY, GLENN P JR (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:P
Last Name:DEWBERRY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE #140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:2701 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5246
Practice Address - Country:US
Practice Address - Phone:405-755-4050
Practice Address - Fax:405-752-1553
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2014-04-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK11240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100110540BMedicaid
OK11240OtherLICENSE
OK080156332OtherRAILROAD
OK15648OtherOBNDD
OK244430904Medicare PIN
OK100110540BMedicaid