Provider Demographics
NPI:1982636155
Name:KIDWELL, MONICA S (DO)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:S
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31870 E STATE HIGHWAY 51
Mailing Address - Street 2:P.O. BOX 900
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7900
Mailing Address - Country:US
Mailing Address - Phone:918-279-3200
Mailing Address - Fax:918-279-1118
Practice Address - Street 1:31870 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7900
Practice Address - Country:US
Practice Address - Phone:918-279-3200
Practice Address - Fax:918-279-1118
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2586208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1202586Medicaid