Provider Demographics
NPI:1548365117
Name:GRIFFIN, CARL N (DO)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:N
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:PO BOX 269064
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9064
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-272-7977
Practice Address - Street 1:6908 E RENO AVE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2128
Practice Address - Country:US
Practice Address - Phone:405-737-7000
Practice Address - Fax:405-737-7700
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK03095207Q00000X
OK3095207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200102570AMedicaid
OK73-0804209OtherTAX ID
OK730804209001OtherBC GROUP NUMBER
F77228Medicare UPIN
OK73-0804209OtherTAX ID
OK400522292Medicare PIN