Provider Demographics
NPI:1619050622
Name:ERBA, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:ERBA
Suffix:
Gender:M
Credentials:MD
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 5096
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-5096
Mailing Address - Country:US
Mailing Address - Phone:580-233-3843
Mailing Address - Fax:580-548-1484
Practice Address - Street 1:600 S MONROE ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7211
Practice Address - Country:US
Practice Address - Phone:580-233-3843
Practice Address - Fax:580-548-1484
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164112085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731440959OtherTAX PAYER ID NUMBER
OK300006050OtherRAILROAD MC
OKA0001OtherTRICARE
OK100003480AMedicaid
OK788007OtherFIRST HEALTH
OK300006050OtherRAILROAD MC