Healthcare Provider Details

I. General information

NPI: 1710239645
Provider Name (Legal Business Name): OKLAHOMA SPORTS AND ORTHOPEDICS INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S TELEPHONE RD STE 207
MOORE OK
73160-5423
US

IV. Provider business mailing address

3400 W TECUMSEH RD STE 101
NORMAN OK
73072-1810
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-6764
  • Fax: 405-360-6769
Mailing address:
  • Phone: 405-360-6764
  • Fax: 405-360-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON PENICK
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 405-360-6764