1497840904 NPI number — BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYSICIANS LATINO CLINIC

Table of content: (NPI 1497840904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497840904 NPI number — BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYSICIANS LATINO CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYSICIANS LATINO CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1497840904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1122 NE 13
Provider Second Line Business Mailing Address:
ORI236
Provider Business Mailing Address City Name:
OKC
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-271-1515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 SW 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKC
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-232-4160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MADDY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
405-271-1515

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100744720X , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200284890A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com