Provider Demographics
NPI:1861413510
Name:MICHELLE L FUGITT DO PLLC
Entity type:Organization
Organization Name:MICHELLE L FUGITT DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FUGITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-392-7606
Mailing Address - Street 1:1615 S EUCALYPTUS AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5990
Mailing Address - Country:US
Mailing Address - Phone:918-392-7606
Mailing Address - Fax:918-392-7607
Practice Address - Street 1:1615 S EUCALYPTUS AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5990
Practice Address - Country:US
Practice Address - Phone:918-392-7606
Practice Address - Fax:918-392-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKIO6166Medicare UPIN