Provider Demographics
NPI:1679594733
Name:CLAREMORE PODIATRY, P.C.
Entity Type:Organization
Organization Name:CLAREMORE PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-341-6821
Mailing Address - Street 1:1218 N FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3109
Mailing Address - Country:US
Mailing Address - Phone:918-341-6821
Mailing Address - Fax:918-342-8128
Practice Address - Street 1:1218 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3109
Practice Address - Country:US
Practice Address - Phone:918-341-6821
Practice Address - Fax:918-342-8128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200051750AMedicaid
OK200051750AMedicaid
5580180001Medicare NSC