1982991444 NPI number — JOSHUA KELLEY D.P.T.

Table of content: JOSHUA KELLEY D.P.T. (NPI 1982991444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982991444 NPI number — JOSHUA KELLEY D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
JOSHUA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
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:
1982991444
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4812 E 33RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-622-4126
Provider Business Mailing Address Fax Number:
918-270-2398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 E 4TH ST
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:
74103-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-382-0200
Provider Business Practice Location Address Fax Number:
918-382-0218
Provider Enumeration Date:
07/06/2011

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: 225100000X , with the licence number:  4474 , 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: 200034500E , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500G , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500F , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500H , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200034500I , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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