1720467483 NPI number — METRO TULSA FOOT & ANKLE SPECIALIST PLLC

Table of content: HERALDINE JESAH ROUS MASSARI (NPI 1538636048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720467483 NPI number — METRO TULSA FOOT & ANKLE SPECIALIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO TULSA FOOT & ANKLE SPECIALIST PLLC
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:
1720467483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3627 S HARVARD AVE
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:
74135-2227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-477-4855
Provider Business Mailing Address Fax Number:
918-301-0088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 S HARVARD AVE
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:
74135-2227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-494-2902
Provider Business Practice Location Address Fax Number:
918-494-2905
Provider Enumeration Date:
05/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JAMISON
Authorized Official First Name:
DANA
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
918-494-2902

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  154 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: 154 , 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: 1168810005 . This is a "DME PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1168810005 . This is a "NSC" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1720467483 . This is a "DME NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 731510850 . This is a "TAX ID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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