Healthcare Provider Details

I. General information

NPI: 1699339804
Provider Name (Legal Business Name): OKLAHOMA MOBILE PODIATRY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S BROADWAY STE 110
EDMOND OK
73013-4065
US

IV. Provider business mailing address

2300 S BROADWAY STE 110
EDMOND OK
73013-4065
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-8900
  • Fax: 405-285-8921
Mailing address:
  • Phone: 405-285-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN DUCK
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 54-285-8900