Provider Demographics
NPI:1710654249
Name:BREWER, DAVID WAYNE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:BREWER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 SW 46TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-7307
Mailing Address - Country:US
Mailing Address - Phone:405-476-7400
Mailing Address - Fax:
Practice Address - Street 1:1501 COMMERCE STREET
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-422-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty