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Individual

GLEN EDWARD DIACON JR.

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
1414 ARLINGTON ST, SUITE 2300, ADA, OK 74820-2643
(580) 332-0112
(580) 332-1005
Mailing address
1414 ARLINGTON ST, SUITE 2300, ADA, OK 74820-2643
(580) 332-0112
(580) 332-1005

Taxonomy

Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
16231
OK

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
100137260A
OK
Enumeration date
09/13/2005
Last updated
08/11/2010
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