Provider Demographics
NPI:1699842161
Name:O'GRADY, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:O'GRADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:
Practice Address - Street 1:1221 ARLINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4067
Practice Address - Country:US
Practice Address - Phone:580-436-5111
Practice Address - Fax:580-436-1159
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9770208000000X
OK17834208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58220Medicare UPIN