1992776058 NPI number — MARY JOSEPHINE BECERRA LD

Table of content: MARY JOSEPHINE BECERRA LD (NPI 1992776058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992776058 NPI number — MARY JOSEPHINE BECERRA LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECERRA
Provider First Name:
MARY
Provider Middle Name:
JOSEPHINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VINCENT
Provider Other First Name:
MARY
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1992776058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 W 9TH 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:
74127-9020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-599-5744
Provider Business Mailing Address Fax Number:
918-599-1763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
744 W 9TH 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:
74127-9020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-599-5744
Provider Business Practice Location Address Fax Number:
918-599-1763
Provider Enumeration Date:
01/27/2006

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: 133V00000X , with the licence number:  1355 , 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: 200054920A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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