Provider Demographics
NPI:1487623294
Name:CROWELL, CHARLES P III (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:CROWELL
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1031
Practice Address - Country:US
Practice Address - Phone:918-885-4640
Practice Address - Fax:918-885-4644
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100190910BMedicaid
OKP00473691Medicare PIN
OK100190910BMedicaid