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NPI Code Detail

MEDICARE: DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC

MEDICARE: DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC
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
1207N00000XDermatology Physician

General Provider Information

NPI Number : 1659779973
Entity Type Code : Organization
Provider Name (Legal Business Name) : DERMATOLOGY ASSOCIATES OF OKLAHOMA LLC
Provider Business Mailing Address
First Line : 6966 S UTICA AVE
Second Line : STE. 225
City : TULSA
State : OK
Zip : 74136-3903
Country : US
Telephone Number : 918-492-6333
Fax Number : 918-493-9405
Provider Business Practice Location Address
First Line : 4805 S WESTERN AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73109-3835
Country : US
Telephone Number : 918-492-6333
Fax Number : 918-493-9405
Authorized Official
Title or Position : MEMBER
Name : ROBERT NEVIN
Credential :
Telephone Number : 918-492-6333
Provider Enumeration Date : 12/18/2014
Last Update Date : 12/18/2014

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