Provider Demographics
NPI:1861464752
Name:LOFGREN, MARTY MARLON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTY
Middle Name:MARLON
Last Name:LOFGREN
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 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:15951 LITTLE AXE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73026-9088
Practice Address - Country:US
Practice Address - Phone:405-447-0300
Practice Address - Fax:405-701-7914
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200173680BMedicaid
OK200173680AMedicaid
OKOK403837Medicare PIN
OKOKAAA0149Medicare PIN
OK200173680BMedicaid