Provider Demographics
NPI:1154390672
Name:GEBETSBERGER, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GEBETSBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4512
Mailing Address - Country:US
Mailing Address - Phone:918-227-1000
Mailing Address - Fax:918-293-3310
Practice Address - Street 1:1021 E BRYAN AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4512
Practice Address - Country:US
Practice Address - Phone:918-227-1000
Practice Address - Fax:918-293-3310
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC94961Medicare UPIN