1649203209 NPI number — MR. DONALD A DESALVO CRNA

Table of content: MR. DONALD A DESALVO CRNA (NPI 1649203209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649203209 NPI number — MR. DONALD A DESALVO CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESALVO
Provider First Name:
DONALD
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1649203209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3456
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLESVILLE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74006-3456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-333-4100
Provider Business Mailing Address Fax Number:
918-333-4106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 E FRANK PHILLIPS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTLESVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74006-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-331-1555
Provider Business Practice Location Address Fax Number:
918-333-1695
Provider Enumeration Date:
07/08/2006

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: 367500000X , with the licence number:  680876 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: R 88186 , 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: 20086500A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010672601002 . This is a "BCBSOK" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200086500A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".