Provider Demographics
NPI:1932195849
Name:GRIFFIN, GARY E (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-736-6811
Mailing Address - Fax:405-736-6863
Practice Address - Street 1:1212 S DOUGLAS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5259
Practice Address - Country:US
Practice Address - Phone:405-736-6811
Practice Address - Fax:405-736-6863
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1832207Q00000X
OK3822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134702003Medicaid
OK100091670AMedicaid
OK100091670AMedicaid
AR134702003Medicaid