Provider Demographics
NPI:1619966108
Name:RADER, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:RADER
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 1:1121 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-5103
Mailing Address - Country:US
Mailing Address - Phone:580-243-3376
Mailing Address - Fax:580-243-3377
Practice Address - Street 1:1121 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-5103
Practice Address - Country:US
Practice Address - Phone:580-243-3376
Practice Address - Fax:580-243-3377
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18832207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF78531Medicare UPIN
OKOK700270Medicare PIN
OK070011957Medicare PIN