Healthcare Provider Details

I. General information

NPI: 1174572838
Provider Name (Legal Business Name): DR. SURESH BHARANI
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S ASPEN AVE SUITE B
BROKEN ARROW OK
74012-7501
US

IV. Provider business mailing address

3300 S ASPEN AVE SUITE B
BROKEN ARROW OK
74012-7501
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-4140
  • Fax:
Mailing address:
  • Phone: 918-455-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12973
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: