Healthcare Provider Details

I. General information

NPI: 1265879175
Provider Name (Legal Business Name): BROKEN ARROW PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N ELM PL
BROKEN ARROW OK
74012-1616
US

IV. Provider business mailing address

1220 N ELM PL
BROKEN ARROW OK
74012-1616
US

V. Phone/Fax

Practice location:
  • Phone: 918-258-1955
  • Fax:
Mailing address:
  • Phone: 918-258-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12938
License Number StateOK

VIII. Authorized Official

Name: DR. CARL ERWIN PFANSTIEL
Title or Position: OWNER
Credential: M.D.
Phone: 918-258-1955