Provider Demographics
NPI:1639192651
Name:CORKRAN, SUSAN MOORE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MOORE
Last Name:CORKRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1413 S WESTERN RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-6957
Mailing Address - Country:US
Mailing Address - Phone:405-533-2844
Mailing Address - Fax:405-533-4035
Practice Address - Street 1:1413 S WESTERN RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6957
Practice Address - Country:US
Practice Address - Phone:405-533-2844
Practice Address - Fax:405-533-4035
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK167432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100033910AMedicaid
OK16743OtherMEDICAL LICENSE
OK100033910AMedicaid
OK$$$$$$$$$WMedicare PIN