MEDICARE: INNOVATIVE MEDICAL ASSOCIATES PLLC

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407066228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE MEDICAL ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	1225 W MAIN ST
Second Line	:	SUITE 205
City	:	NORMAN
State	:	OK
Zip	:	73069-6824
Country	:	US
Telephone Number	:	405-292-5500
Fax Number	:	405-292-5505

Provider Business Practice Location Address
First Line	:	4301 NW 63RD ST
Second Line	:	SUITE 205
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1549
Country	:	US
Telephone Number	:	405-242-6494
Fax Number	:	405-242-6496

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	VATSALA SHAH
Credential	:	MD
Telephone Number	:	405-553-1540

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	01/07/2016

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