Healthcare Provider Details

I. General information

NPI: 1114334885
Provider Name (Legal Business Name): PARK PLACE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARK PL
MUSTANG OK
73064-3104
US

IV. Provider business mailing address

500 PARK PL
MUSTANG OK
73064-3104
US

V. Phone/Fax

Practice location:
  • Phone: 406-376-5439
  • Fax: 405-376-6459
Mailing address:
  • Phone: 406-376-5439
  • Fax: 405-376-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15742
License Number StateOK

VIII. Authorized Official

Name: DR. DONNA RAYE COSBY
Title or Position: OWNER
Credential: MD
Phone: 405-376-5439