Provider Demographics
NPI:1760450480
Name:LAW, MAGGIE SW (MD)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:SW
Last Name:LAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S 40TH ST
Mailing Address - Street 2:CCOM MEDICAL GROUP
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4915
Mailing Address - Country:US
Mailing Address - Phone:918-683-0753
Mailing Address - Fax:
Practice Address - Street 1:350 S 40TH ST
Practice Address - Street 2:CCOM MEDICAL GROUP
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4915
Practice Address - Country:US
Practice Address - Phone:918-683-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19934207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100224720AMedicaid
OK100224720AMedicaid