Provider Demographics
NPI:1750013652
Name:ATADDLETY, CORWIN JOHN
Entity Type:Individual
Prefix:MR
First Name:CORWIN
Middle Name:JOHN
Last Name:ATADDLETY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CORWIN
Other - Middle Name:JOHN
Other - Last Name:ATADDLETY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:221 WICHITA DR
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-3705
Mailing Address - Country:US
Mailing Address - Phone:405-933-2258
Mailing Address - Fax:
Practice Address - Street 1:423 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-2111
Practice Address - Country:US
Practice Address - Phone:405-247-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK034621147OtherSOONERCARE