Provider Demographics
NPI:1104879410
Name:DEITER, RAYMOND W (DO, PC)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:W
Last Name:DEITER
Suffix:
Gender:M
Credentials:DO, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9104
Mailing Address - Country:US
Mailing Address - Phone:405-632-7256
Mailing Address - Fax:405-602-6420
Practice Address - Street 1:1100 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9104
Practice Address - Country:US
Practice Address - Phone:405-632-7256
Practice Address - Fax:405-602-6420
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100194840AMedicaid
OK100194840AMedicaid
OKD38532Medicare UPIN