Provider Demographics
NPI:1588912034
Name:CARRISSA CANDLER MD PLLC
Entity type:Organization
Organization Name:CARRISSA CANDLER MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-936-0504
Mailing Address - Street 1:120 N BRYANT AVE STE A6
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6300
Mailing Address - Country:US
Mailing Address - Phone:405-936-0504
Mailing Address - Fax:405-936-0561
Practice Address - Street 1:120 N BRYANT AVE STE A6
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6300
Practice Address - Country:US
Practice Address - Phone:405-936-0504
Practice Address - Fax:405-936-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20774207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200166550AMedicaid
OKOKB5621Medicare PIN