Provider Demographics
NPI:1871505784
Name:CRAIG, GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:CRAIG
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 1:2321 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-1831
Mailing Address - Country:US
Mailing Address - Phone:918-622-0641
Mailing Address - Fax:918-622-4814
Practice Address - Street 1:2321 E 3RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-1831
Practice Address - Country:US
Practice Address - Phone:918-622-0641
Practice Address - Fax:918-622-4814
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100094650AMedicaid
OK100094650AMedicaid