Healthcare Provider Details

I. General information

NPI: 1801926647
Provider Name (Legal Business Name): MUSKOGEE ALLERGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 WEST OKMULGEE STREET
MUSKOGEE OK
74401
US

IV. Provider business mailing address

3316 WEST OKMULGEE STREET
MUSKOGEE OK
74401
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-1425
  • Fax: 918-682-0615
Mailing address:
  • Phone: 918-682-1425
  • Fax: 918-682-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number3158
License Number StateOK

VIII. Authorized Official

Name: DR. EVAN DEAN COLE
Title or Position: MANAGING PHYSICIAN
Credential: DO
Phone: 19-682-1425