Provider Demographics
NPI:1700874914
Name:FAIRLIE, GREGORY WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WILLIAM
Last Name:FAIRLIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3555 NW 58TH ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4707
Mailing Address - Country:US
Mailing Address - Phone:405-917-0418
Mailing Address - Fax:405-917-0419
Practice Address - Street 1:13420 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9007
Practice Address - Country:US
Practice Address - Phone:405-478-0633
Practice Address - Fax:405-478-5218
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI02169Medicare UPIN
OK248411901Medicare ID - Type Unspecified