Healthcare Provider Details

I. General information

NPI: 1659562635
Provider Name (Legal Business Name): DEEPTI GANTI CHRUSCIEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 NW 39TH EXPY
BETHANY OK
73008-2513
US

IV. Provider business mailing address

6800 NW 39TH EXPY
BETHANY OK
73008-2513
US

V. Phone/Fax

Practice location:
  • Phone: 405-440-9866
  • Fax: 405-438-3834
Mailing address:
  • Phone: 405-440-9866
  • Fax: 405-438-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007016654
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: