MEDICARE: DR. SUSANNA V. ULAHANNAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	30484EFF	OK
2	207RH0000X	Hematology (Internal Medicine) Physician	30484EFF	OK
3	207RX0202X	Medical Oncology Physician	30484EFF	OK

General Provider Information

NPI Number	:	1033369988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSANNA V. ULAHANNAN M.D.

Provider Business Mailing Address
First Line	:	609 VIRGINIA AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2911
Country	:	US
Telephone Number	:	580-767-1300
Fax Number	:	580-765-4529

Provider Business Practice Location Address
First Line	:	609 VIRGINIA AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2911
Country	:	US
Telephone Number	:	580-767-1300
Fax Number	:	580-765-4529

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2008
Last Update Date	:	05/15/2015

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