Provider Demographics
NPI:1659394765
Name:JANZEN, DWAYNE LEE (D O)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:LEE
Last Name:JANZEN
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:580-977-1910
Mailing Address - Fax:580-237-1925
Practice Address - Street 1:915 E GARRIOTT RD STE A
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6153
Practice Address - Country:US
Practice Address - Phone:580-977-1910
Practice Address - Fax:580-237-1925
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34426207Q00000X
OK1639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100252020CMedicaid
OK730936109OtherTAX ID NUMBER
OK100252020CMedicaid
OK730936109005OtherBC/BS OF OKLAHOMA
730936109OtherA W JANZEN DO INC-TIN
OK100252020CMedicaid