Provider Demographics
NPI:1619975745
Name:CHARBONEAU, SEMIRA (DO)
Entity Type:Individual
Prefix:DR
First Name:SEMIRA
Middle Name:
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-9149
Practice Address - Street 1:905 COLONY DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2329
Practice Address - Country:US
Practice Address - Phone:580-436-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200011300AMedicaid
OKP00035275OtherRAILDROAD MEDICARE
OK200011300AMedicaid
OK241320506Medicare Oscar/Certification