Provider Demographics
NPI:1972631067
Name:DARYL E. BIRDWELL, M.D., INC.
Entity type:Organization
Organization Name:DARYL E. BIRDWELL, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-248-7417
Mailing Address - Street 1:4417 W GORE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5978
Mailing Address - Country:US
Mailing Address - Phone:580-248-7417
Mailing Address - Fax:580-248-4847
Practice Address - Street 1:4417 W GORE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5978
Practice Address - Country:US
Practice Address - Phone:580-248-7417
Practice Address - Fax:580-248-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10548OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10548OKOtherSTATE LIC.
OK100094050AMedicaid
OK100094050AMedicaid
OK100094050AMedicaid
OK10548OKOtherSTATE LIC.