Provider Demographics
NPI:1871581470
Name:METTRY, CHARLES R (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:METTRY
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:201 N MONTE VISTA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7213
Mailing Address - Country:US
Mailing Address - Phone:580-436-4200
Mailing Address - Fax:580-436-6423
Practice Address - Street 1:201 N MONTE VISTA ST
Practice Address - Street 2:SUITE B
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7200
Practice Address - Country:US
Practice Address - Phone:580-436-4200
Practice Address - Fax:580-436-6423
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2009-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK22062080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK38-2376906OtherFED ID
OK100111120AMedicaid
OK100111120AMedicaid