Provider Demographics
NPI:1659405488
Name:BROKEN ARROW FAMILY PRACTICE CENTER
Entity Type:Organization
Organization Name:BROKEN ARROW FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-251-2273
Mailing Address - Street 1:817 S ELM PL STE A
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-251-2273
Mailing Address - Fax:918-258-6446
Practice Address - Street 1:817 S ELM PL STE A
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-251-2273
Practice Address - Fax:918-258-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100172440DMedicaid
P00389602OtherRAILROAD MEDICARE
P00389602OtherRAILROAD MEDICARE