Healthcare Provider Details

I. General information

NPI: 1255671806
Provider Name (Legal Business Name): ADA PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 ARLINGTON ST SUITE 1700
ADA OK
74820-2646
US

IV. Provider business mailing address

1414 ARLINGTON ST SUITE 1700
ADA OK
74820-2646
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-7337
  • Fax: 580-332-3881
Mailing address:
  • Phone: 580-332-7337
  • Fax: 580-332-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16267
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0065815
License Number StateOK

VIII. Authorized Official

Name: RUTH WEESNER
Title or Position: OWNER
Credential: M.D.
Phone: 580-332-7337