Provider Demographics
NPI:1336447135
Name:HAISLIP, HEIDI L (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:L
Last Name:HAISLIP
Suffix:
Gender:F
Credentials:MD
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:405-379-4200
Mailing Address - Fax:
Practice Address - Street 1:1401 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-5097
Practice Address - Country:US
Practice Address - Phone:405-257-3396
Practice Address - Fax:405-257-6908
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200339360AMedicaid
OK200339360AMedicaid