Unknown Individual – Cardiovascular Disease Physician, NPI 1124096813

Unknown Individual is a healthcare provider. based in Muskogee, Oklahoma. specializing in Cardiovascular Disease Physician. They hold a License No. 12244 (OK). The NPI Number for Unknown Individual is 1124096813

Main info

Organization
Inactive
54 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1124096813
Phone
(918) 683-0753
Address
350 S 40TH ST
Deactivation Date
29 March 2021

Doctor Profile

Medical School Name
OTHER
Secondary Phone
9186830753
Graduation Year
1972 (54 years ago)
PAC ID
4587644695
Group Practice PAC ID
5193710101
Professional Enrollment ID
I20091201000318
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • 350, South 40th Street, Muskogee, Muskogee County, Oklahoma, 74401, United States

    CCOM MEDICAL GROUP

    MUSKOGEE, OK 744014915

    Phone: (918) 683-0753

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 74401)

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Provider's Procedures

Unknown Individual performs procedures in Cardiovascular Disease Physician. See the list of HCPCS codes below.
SpecialtyPractice State
HCPCS Code
Description
Service Count
Beneficiary Count
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK73110X-ray of wrist, minimum of 3 views2121
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK73630X-ray of foot, minimum of 3 views7067
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK78452Nuclear medicine study of vessels of heart using drugs or exercise multiple studies215201
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK85610Blood test, clotting time637114
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK93010Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report1807971
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK93284Evaluation, testing and programming adjustment of defibrillator with analysis, review and report1512
CARDIOVASCULAR DISEASE (CARDIOLOGY)OK96375Injection of different drug or substance into a vein for therapy, diagnosis, or prevention414217

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 5193710101View full group profile

Reviews

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Frequently asked questions

Is there an official ID for Unknown Individual in U.S. healthcare records?
The official identifier for Unknown Individual is NPI 1124096813.
Does inactive status mean Unknown Individual stopped practicing?
Inactive registry status can reflect deactivation, consolidation, or data lag.
What clinical focus is listed for Unknown Individual?
At a glance, Unknown Individual is tied to Cardiovascular Disease Physician. Clinical services aligned with this taxonomy classification.
Is Unknown Individual located near Muskogee?
Unknown Individual currently maps to Muskogee, Oklahoma in this extract.
Does inactive status remove historical data?
Historical rows can remain visible after status changes — read the dates carefully.

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