1134349582 NPI number — DR. DOROTHY LYNETTE MILLICAN PH.D.

Table of content: DR. DOROTHY LYNETTE MILLICAN PH.D. (NPI 1134349582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134349582 NPI number — DR. DOROTHY LYNETTE MILLICAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLICAN
Provider First Name:
DOROTHY
Provider Middle Name:
LYNETTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLICAN-WYNN
Provider Other First Name:
DOROTHY
Provider Other Middle Name:
LYNETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134349582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 52135 DOROTHY MILLICAN
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:
74152-0135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-740-4066
Provider Business Mailing Address Fax Number:
918-742-4900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
THE ELITE MEDICAL CLINIC
Provider Second Line Business Practice Location Address:
3336 E 32ND STREET
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-4448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-740-4066
Provider Business Practice Location Address Fax Number:
918-670-7364
Provider Enumeration Date:
04/26/2007

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: 103TC1900X , with the licence number:  634 , 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: 100837450 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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