Provider Demographics
NPI:1912043019
Name:MICHAEL D JOHN MD PC
Entity Type:Organization
Organization Name:MICHAEL D JOHN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-359-0551
Mailing Address - Street 1:620 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3617
Mailing Address - Country:US
Mailing Address - Phone:405-359-0551
Mailing Address - Fax:405-359-3061
Practice Address - Street 1:620 W 15TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3617
Practice Address - Country:US
Practice Address - Phone:405-359-0551
Practice Address - Fax:405-359-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15126207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2532523004OtherCIGNA
OK4234977OtherAETNA
OK402760407001OtherBLUE CROSS BLUE SHIEL
OK4234977OtherAETNA