Healthcare Provider Details

I. General information

NPI: 1730154170
Provider Name (Legal Business Name): IWAN T TJAUW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 NW 54TH ST SUITE C-40
OKLAHOMA CITY OK
73112-4455
US

IV. Provider business mailing address

3433 NW 54TH ST SUITE C-40
OKLAHOMA CITY OK
73112-4455
US

V. Phone/Fax

Practice location:
  • Phone: 405-945-4741
  • Fax: 888-972-5320
Mailing address:
  • Phone: 405-945-4741
  • Fax: 888-972-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number24754
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number24754
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: