1922107648 NPI number — MRS. ADELAIDE L PRIESTER D.O.

Table of content: MRS. ADELAIDE L PRIESTER D.O. (NPI 1922107648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922107648 NPI number — MRS. ADELAIDE L PRIESTER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRIESTER
Provider First Name:
ADELAIDE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1922107648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
244 S. GATEWAY PLACE
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
JENKS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-747-2020
Provider Business Mailing Address Fax Number:
918-747-2056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4444 S HARVARD AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-747-2020
Provider Business Practice Location Address Fax Number:
918-747-2056
Provider Enumeration Date:
09/21/2006

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: 207W00000X , with the licence number:  2472 , 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: 100176260A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457746 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 4573409 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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