Healthcare Provider Details

I. General information

NPI: 1285260679
Provider Name (Legal Business Name): MOSAIC FOUNDATION SOUTH OKC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 SE 44TH ST
OKLAHOMA CITY OK
73129-6906
US

IV. Provider business mailing address

701 NE 36TH ST
OKLAHOMA CITY OK
73105-7203
US

V. Phone/Fax

Practice location:
  • Phone: 405-631-0611
  • Fax:
Mailing address:
  • Phone: 405-445-7492
  • Fax: 405-445-7492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT MAYER
Title or Position: DIRECTOR
Credential: MD
Phone: 405-445-7492