1255395984 NPI number — LESA JEAN BETHEL MULLIGAN MD

Table of content: JOSIE YOUNG (NPI 1861163578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255395984 NPI number — LESA JEAN BETHEL MULLIGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETHEL MULLIGAN
Provider First Name:
LESA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BETHEL MULLIGAN
Provider Other First Name:
LESA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255395984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1139 36TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73072-4103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-364-0643
Provider Business Mailing Address Fax Number:
405-364-0502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1139 36TH AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73072-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-364-0643
Provider Business Practice Location Address Fax Number:
405-364-0502
Provider Enumeration Date:
04/12/2006

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: 207V00000X , with the licence number:  18183 , 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: 100131240B . This is a "SOONERCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100131240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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