Provider Demographics
NPI:1295920734
Name:LOFTIN FAMILY PRACTICE
Entity type:Organization
Organization Name:LOFTIN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:LOFTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-456-3425
Mailing Address - Street 1:1323 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3462
Mailing Address - Country:US
Mailing Address - Phone:918-456-3425
Mailing Address - Fax:918-456-3107
Practice Address - Street 1:1323 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3462
Practice Address - Country:US
Practice Address - Phone:918-456-3425
Practice Address - Fax:918-456-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22820261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG57050Medicare UPIN