Basic Information
| Provider Information | |||||||||
| NPI: | 1730522129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHARITY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLDER | ||||||||
| OtherFirstName: | CHARITY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886045 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LONE OAK CIR | ||||||||
| Address2: | |||||||||
| City: | FORT GIBSON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744345001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184786005 | ||||||||
| FaxNumber: | 9184786020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5395 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.