Provider Demographics
NPI:1376669986
Name:MAYNARD, DALE WAYNE JR (DC)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:WAYNE
Last Name:MAYNARD
Suffix:JR
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 1:5113 SE 15TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3952
Mailing Address - Country:US
Mailing Address - Phone:405-601-0700
Mailing Address - Fax:405-605-5776
Practice Address - Street 1:5113 SE 15TH ST STE C
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3952
Practice Address - Country:US
Practice Address - Phone:405-601-0700
Practice Address - Fax:405-605-5776
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3752111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK432065001-001OtherBCBS PROVIDER NUMBER
OK432065001-001OtherBCBS PROVIDER NUMBER
OK900522329Medicare ID - Type UnspecifiedGROUP