Healthcare Provider Details

I. General information

NPI: 1245521889
Provider Name (Legal Business Name): LISA DIANE MACEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA DIANE RYAN M.D.

II. Dates (important events)

Enumeration Date: 05/01/2011
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 S ELM PL SUITE 160
BROKEN ARROW OK
74012-7877
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-449-3750
  • Fax: 918-449-3755
Mailing address:
  • Phone: 918-488-6001
  • Fax: 918-488-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28585
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: