MEDICARE: DR. RUSSELL DALE GILSTRAP D.C.

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	111N00000X	Chiropractor	2449	OK
2	363LF0000X	Family Nurse Practitioner	97265	OK

General Provider Information

NPI Number	:	1659455517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL DALE GILSTRAP D.C.

Provider Business Mailing Address
First Line	:	3900 S 113TH WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-2724
Country	:	US
Telephone Number	:	918-241-3901
Fax Number	:	918-241-3902

Provider Business Practice Location Address
First Line	:	3900 S 113TH WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-2724
Country	:	US
Telephone Number	:	918-241-3901
Fax Number	:	918-241-3902

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	01/13/2012

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