Provider Demographics
NPI:1528050085
Name:UNDERWOOD, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:UNDERWOOD
Suffix:
Gender:M
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:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74362-0913
Mailing Address - Country:US
Mailing Address - Phone:918-825-4299
Mailing Address - Fax:
Practice Address - Street 1:900 N OWEN WALTERS BLVD
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:OK
Practice Address - Zip Code:74365-5003
Practice Address - Country:US
Practice Address - Phone:918-434-8500
Practice Address - Fax:918-434-8150
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG13546Medicare UPIN