Healthcare Provider Details

I. General information

NPI: 1104943547
Provider Name (Legal Business Name): JOHN MARK HEUSMAN MS, LAT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

6201 N SANTA FE AVE
OKLAHOMA CITY OK
73118-7538
US

IV. Provider business mailing address

8320 NW 111TH TER
OKLAHOMA CITY OK
73162-2100
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-5478
  • Fax:
Mailing address:
  • Phone: 405-818-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT-82
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: