Provider Demographics
NPI:1215239066
Name:MAYNARD, PHILIP CAMERON
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:CAMERON
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DBA-MAYNARD
Other - Middle Name:FAMILY
Other - Last Name:CHIROPRACTIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8922 S MEMORIAL DR STE C1
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4343
Mailing Address - Country:US
Mailing Address - Phone:918-704-3999
Mailing Address - Fax:
Practice Address - Street 1:8922 S MEMORIAL DR STE C1
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4343
Practice Address - Country:US
Practice Address - Phone:918-704-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3994111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB6037OtherPTAN#