Provider Demographics
NPI:1144295775
Name:REDWINE, SUSAN T (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:REDWINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6273
Mailing Address - Country:US
Mailing Address - Phone:406-330-7000
Mailing Address - Fax:
Practice Address - Street 1:200 N BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6273
Practice Address - Country:US
Practice Address - Phone:405-330-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22619208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200066430AMedicaid
OK22619OtherLICENSE
OK30634OtherOBNDD