Provider Demographics
NPI:1912907056
Name:HYDE, GLEN DEWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:DEWAYNE
Last Name:HYDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-283-9000
Mailing Address - Fax:405-283-9025
Practice Address - Street 1:12200 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8762
Practice Address - Country:US
Practice Address - Phone:405-283-9000
Practice Address - Fax:405-283-9025
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100096910DMedicaid
OKP00651090Medicare PIN
OKOK700359Medicare PIN
H19246Medicare UPIN
OK248510905Medicare PIN