Provider Demographics
NPI:1548218803
Name:ROTTON, DAVID BRENT (DO, FACOS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRENT
Last Name:ROTTON
Suffix:
Gender:M
Credentials:DO, FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-207-1410
Mailing Address - Fax:918-207-0335
Practice Address - Street 1:1500 E. DOWNING
Practice Address - Street 2:#103
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-207-1140
Practice Address - Fax:918-207-0335
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118997208600000X
OK3315208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020043303OtherMEDICARE RAILROAD
MO244688909Medicaid
MOCF9170OtherMEDICARE RAILROAD
OK100102820AMedicaid
MO002013126Medicare PIN
MOCF9170OtherMEDICARE RAILROAD
MO020043303OtherMEDICARE RAILROAD