Provider Demographics
NPI:1902836901
Name:CRITTENDEN, MICKEY E (MD)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:E
Last Name:CRITTENDEN
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE #140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:1919 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1253
Practice Address - Country:US
Practice Address - Phone:405-341-7009
Practice Address - Fax:405-340-1817
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11345208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK15429OtherOBNDD
OK100110500BMedicaid
OK11345OtherLICENSE
OK15429OtherOBNDD