Provider Demographics
NPI:1609831833
Name:PICKETT, GREG DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:DANIEL
Last Name:PICKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:304 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5753
Mailing Address - Country:US
Mailing Address - Phone:580-379-6500
Mailing Address - Fax:580-379-6509
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:580-379-5000
Practice Address - Fax:580-379-5509
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4548207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200116570AMedicaid
OKP00460271OtherRAILROAD MEDICARE
OK200116570AMedicaid
MO120420Medicare UPIN
TX8L6439Medicare PIN