Provider Demographics
NPI:1700845005
Name:FUGITT, MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:FUGITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 S EUCALYPTUS AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5990
Mailing Address - Country:US
Mailing Address - Phone:918-392-7606
Mailing Address - Fax:918-392-7607
Practice Address - Street 1:1615 S EUCALYPTUS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5990
Practice Address - Country:US
Practice Address - Phone:918-392-7606
Practice Address - Fax:918-392-7607
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI06166Medicare UPIN