Provider Demographics
NPI:1205804424
Name:STEPHENS, GEORGE KELLOGG III (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:KELLOGG
Last Name:STEPHENS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:G
Other - Middle Name:KELLY
Other - Last Name:STEPHENS
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4345 W MEMORIAL RD
Mailing Address - Street 2:STE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1702
Mailing Address - Country:US
Mailing Address - Phone:405-936-5800
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:2017 W I 35 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8504
Practice Address - Country:US
Practice Address - Phone:405-757-3365
Practice Address - Fax:405-757-3498
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100128790BMedicaid
OK100128790BMedicaid