Provider Demographics
NPI:1184707457
Name:DUFFY, DOUGLAS (PAC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:DUFFY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MCDOUGAL DR
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-2822
Mailing Address - Country:US
Mailing Address - Phone:580-272-0018
Mailing Address - Fax:580-272-0657
Practice Address - Street 1:520 N MONTE VISTA ST STE C
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4674
Practice Address - Country:US
Practice Address - Phone:580-272-0018
Practice Address - Fax:580-272-0657
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002737363AS0400X
OK407363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200194390AMedicaid
MIM05960P03Medicare ID - Type Unspecified
OK200194390AMedicaid