Healthcare Provider Details

I. General information

NPI: 1073263380
Provider Name (Legal Business Name): SOUTHSIDE DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S ASPEN AVE STE A
BROKEN ARROW OK
74012-7501
US

IV. Provider business mailing address

6966 S UTICA AVE STE 225
TULSA OK
74136-3903
US

V. Phone/Fax

Practice location:
  • Phone: 918-760-0700
  • Fax:
Mailing address:
  • Phone: 918-492-6333
  • Fax: 918-493-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALISON FISCHER
Title or Position: OWNER
Credential:
Phone: 918-760-0700