Healthcare Provider Details

I. General information

NPI: 1699175943
Provider Name (Legal Business Name): ROBERT M POLK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2014
Last Update Date: 08/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W TECUMSEH RD
NORMAN OK
73072-1810
US

IV. Provider business mailing address

3400 W TECUMSEH RD
NORMAN OK
73072-1810
US

V. Phone/Fax

Practice location:
  • Phone: 405-478-7111
  • Fax:
Mailing address:
  • Phone: 405-478-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number709
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: