Provider Demographics
NPI:1689675688
Name:STACEY D KNAPP DO PC INC
Entity Type:Organization
Organization Name:STACEY D KNAPP DO PC INC
Other - Org Name:STACEY D KNAPP DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KNAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-323-7800
Mailing Address - Street 1:209 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3100
Mailing Address - Country:US
Mailing Address - Phone:580-323-7800
Mailing Address - Fax:580-323-7803
Practice Address - Street 1:209 S 30TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3100
Practice Address - Country:US
Practice Address - Phone:580-323-7800
Practice Address - Fax:580-323-7803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20-1347913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522201Medicare PIN