1316331986 NPI number — DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316331986 NPI number — DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316331986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6966 S UTICA AVE
Provider Second Line Business Mailing Address:
STE. 225
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74136-3903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-492-6333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 SW 89TH ST
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73159-7908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-703-2060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NEVIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
918-492-6333

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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