Provider Demographics
NPI:1699756957
Name:INGRAM, FRED M (DO)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:M
Last Name:INGRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3114
Mailing Address - Country:US
Mailing Address - Phone:918-371-5885
Mailing Address - Fax:918-371-5986
Practice Address - Street 1:1205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3114
Practice Address - Country:US
Practice Address - Phone:918-371-5885
Practice Address - Fax:918-371-5986
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2098207Q00000X
TXJ7525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK080114575OtherPALMETTO GBA-RAILROAD
OK731479823001OtherPGBA(TRICARE SOUTH)
OK731479823OtherTRICARE
OK100106080BMedicaid
OK731479823001OtherPGBA(TRICARE SOUTH)