Provider Demographics
NPI:1780688507
Name:PAGE, GARRY THOMAS JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:THOMAS
Last Name:PAGE
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-0745
Mailing Address - Country:US
Mailing Address - Phone:918-478-3388
Mailing Address - Fax:918-478-3397
Practice Address - Street 1:1596 S LEE ST
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-8403
Practice Address - Country:US
Practice Address - Phone:918-478-3388
Practice Address - Fax:918-478-3397
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2010-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK3311111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3311OtherLICENSE NUMBER
U62236Medicare UPIN