Basic Information
| Provider Information | |||||||||
| NPI: | 1972545820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HELTON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 345 | ||||||||
| Address2: | |||||||||
| City: | COALGATE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745380345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
| FaxNumber: | 5809279941 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 W OHIO | ||||||||
| Address2: | |||||||||
| City: | COALGATE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745382827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809272334 | ||||||||
| FaxNumber: | 5809279941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2096 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | 2096 | OK | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100741130B | 05 | OK | MEDICAID | 100741130C | 05 | OK | MEDICAID | 100741130A | 05 | OK | MEDICAID | 100089840A | 05 | OK | MEDICAID |