Provider Demographics
NPI:1902688260
Name:IDLETT, GEORGE CLAYTON
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:CLAYTON
Last Name:IDLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-8934
Mailing Address - Country:US
Mailing Address - Phone:405-857-5322
Mailing Address - Fax:
Practice Address - Street 1:4130 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5209
Practice Address - Country:US
Practice Address - Phone:405-857-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty