Provider Demographics
NPI:1639248149
Name:LANCE E HARDISON DPM PC
Entity Type:Organization
Organization Name:LANCE E HARDISON DPM PC
Other - Org Name:MICHAEL K WILSON DPM INC (OTHER NAME)
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-751-6153
Mailing Address - Street 1:1126 S.W. 89
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9104
Mailing Address - Country:US
Mailing Address - Phone:405-692-7114
Mailing Address - Fax:405-692-2425
Practice Address - Street 1:1126 S.W. 89
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9104
Practice Address - Country:US
Practice Address - Phone:405-692-7114
Practice Address - Fax:405-692-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK151213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4338320001Medicare NSC
OKT80052Medicare UPIN
OKV00088Medicare UPIN
OKU68002Medicare UPIN