Healthcare Provider Details

I. General information

NPI: 1447541750
Provider Name (Legal Business Name): STUART JOSEPH LISLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 NW 23RD ST
BETHANY OK
73008-4921
US

IV. Provider business mailing address

7530 NW 23RD ST
BETHANY OK
73008-4921
US

V. Phone/Fax

Practice location:
  • Phone: 405-787-8562
  • Fax: 405-787-8533
Mailing address:
  • Phone: 405-787-8562
  • Fax: 405-787-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31441
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: