1144218322 NPI number — DR. LAWRENCE CLAY BROTHERTON III MD

Table of content: ANDREA HERNANDEZ LPN (NPI 1194080762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144218322 NPI number — DR. LAWRENCE CLAY BROTHERTON III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROTHERTON
Provider First Name:
LAWRENCE
Provider Middle Name:
CLAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144218322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1725 E 19TH ST
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74104-5472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-301-2505
Provider Business Mailing Address Fax Number:
918-744-3633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 E 19TH ST
Provider Second Line Business Practice Location Address:
SUITE 800
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74104-5472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-301-2505
Provider Business Practice Location Address Fax Number:
918-744-3633
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  24398 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 730768966 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200060600A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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