Provider Demographics
NPI:1548605199
Name:DERBY, MICAH JON (DO)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:JON
Last Name:DERBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 S YALE AVE STE 650
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3342
Practice Address - Country:US
Practice Address - Phone:918-502-7800
Practice Address - Fax:918-502-7815
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK5550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200541190AMedicaid
OK200541190BMedicaid
OK442012YMSDOtherMEDICARE