Provider Demographics
NPI:1801972476
Name:INGRAM, RICHARD EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWARD
Last Name:INGRAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4046
Mailing Address - Country:US
Mailing Address - Phone:918-465-5661
Mailing Address - Fax:918-465-5662
Practice Address - Street 1:208 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4046
Practice Address - Country:US
Practice Address - Phone:918-465-5661
Practice Address - Fax:918-465-5662
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU39869Medicare UPIN
OKOK700440Medicare PIN