Provider Demographics
NPI:1740224955
Name:TALLEY, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:TALLEY
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 1:124 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763
Mailing Address - Country:US
Mailing Address - Phone:580-822-4404
Mailing Address - Fax:580-822-4403
Practice Address - Street 1:124 N 6TH ST
Practice Address - Street 2:
Practice Address - City:OKEENE
Practice Address - State:OK
Practice Address - Zip Code:73763
Practice Address - Country:US
Practice Address - Phone:580-822-4404
Practice Address - Fax:580-822-4403
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00285340OtherRAILROAD MEDICARE
OK730793801003OtherBCBS
OK100123710AMedicaid
371327Medicare Oscar/Certification
OKD35335Medicare UPIN
OK244504804Medicare PIN