Healthcare Provider Details

I. General information

NPI: 1841659125
Provider Name (Legal Business Name): ST ANTHONY PHYSICIANS DERMATOLOGY MIDWEST CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 MIDTOWN PLACE
MIDWEST CITY OK
73130-5266
US

IV. Provider business mailing address

1622 MIDTOWN PLACE
MIDWEST CITY OK
73130-5266
US

V. Phone/Fax

Practice location:
  • Phone: 405-280-7546
  • Fax: 405-772-8674
Mailing address:
  • Phone: 405-280-7546
  • Fax: 405-772-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: INSURANCE CREDENTIALING SPECIALIST
Credential:
Phone: 405-272-7452