MEDICARE: JOHN TODD BASSETT

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	225100000X	Physical Therapist	5513	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5513	OTHER	OK	OK STATE BOARD OF MEDICAL LICENSURE & SUPERVISION

General Provider Information

NPI Number	:	1861972408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN TODD BASSETT

Provider Business Mailing Address
First Line	:	2417 E 53RD ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-6600
Country	:	US
Telephone Number	:	918-712-8412
Fax Number	:	918-712-8413

Provider Business Practice Location Address
First Line	:	2417 E 53RD ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-6600
Country	:	US
Telephone Number	:	918-712-8412
Fax Number	:	918-712-8413

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

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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