Provider Demographics
NPI:1679679062
Name:HARAWAY, GLENN DAVIN (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DAVIN
Last Name:HARAWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 S. YORKTOWN AVE., SUITE C
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-701-2020
Mailing Address - Fax:866-314-4375
Practice Address - Street 1:6901 S. YORKTOWN AVE., SUITE C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-701-2020
Practice Address - Fax:866-314-4375
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163667003Medicaid
OK100254950BMedicaid
G23797Medicare UPIN
AR5N760Medicare PIN