1598966749 NPI number — LARRY GENE DOTSON MS UNDER LPC SUPERVI

Table of content: LARRY GENE DOTSON MS UNDER LPC SUPERVI (NPI 1598966749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598966749 NPI number — LARRY GENE DOTSON MS UNDER LPC SUPERVI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOTSON
Provider First Name:
LARRY
Provider Middle Name:
GENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS UNDER LPC SUPERVI
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:
1598966749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3112 N IRONWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-1769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-698-7684
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 S BOSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74119-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-382-7300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2007

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: 101YM0800X , with the licence number:  UNDER SUPERVISION , 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)





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