1467430496 NPI number — SUSAN BLYTHE YOUNG DO

Table of content: SUSAN BLYTHE YOUNG DO (NPI 1467430496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467430496 NPI number — SUSAN BLYTHE YOUNG DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
SUSAN
Provider Middle Name:
BLYTHE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FINDLEY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467430496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1831 E 71ST 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:
74136-3922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-824-7773
Provider Business Mailing Address Fax Number:
918-824-6410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 NE 1ST ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PRYOR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74361-8850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-824-7767
Provider Business Practice Location Address Fax Number:
918-824-6410
Provider Enumeration Date:
01/09/2006

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: 208600000X , with the licence number:  3799 , 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: 200064490A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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