Healthcare Provider Details

I. General information

NPI: 1760565063
Provider Name (Legal Business Name): RUTH ANN WEESNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 ARLINGTON ST SUITE 1700
ADA OK
74820-2643
US

IV. Provider business mailing address

1414 ARLINGTON ST SUITE 1700
ADA OK
74820-2643
US

V. Phone/Fax

Practice location:
  • Phone: 580-333-7337
  • Fax: 580-332-3881
Mailing address:
  • Phone: 580-333-7337
  • Fax: 580-332-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16267
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100130860B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: