Provider Demographics
NPI:1760635890
Name:MUSTAIN, WILLIAM CONAN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CONAN
Last Name:MUSTAIN
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 1:4205 MCAULEY BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8347
Mailing Address - Country:US
Mailing Address - Phone:405-936-5718
Mailing Address - Fax:405-936-5719
Practice Address - Street 1:4205 MCAULEY BLVD STE 301
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8347
Practice Address - Country:US
Practice Address - Phone:405-936-5718
Practice Address - Fax:405-936-5719
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1900208600000X
ARE-9260208C00000X, 208600000X
OK42838208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5ZZ13OtherAR BCBS
AR209704001Medicaid
AR5ZZ13OtherAR BCBS