Provider Demographics
NPI:1801895776
Name:COLE, EDWIN K (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:K
Last Name:COLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E
Other - Middle Name:KEITH
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:580-249-3898
Mailing Address - Fax:
Practice Address - Street 1:330 S 5TH ST STE 401
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5863
Practice Address - Country:US
Practice Address - Phone:580-249-3898
Practice Address - Fax:580-234-9625
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21807208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP01319276OtherRR MEDICARE
OK200000220COtherMEDICAID OSU AJ
OK200000220BMedicaid
OK318892YKW9Medicare PIN
OK200000220COtherMEDICAID OSU AJ