Healthcare Provider Details

I. General information

NPI: 1851078059
Provider Name (Legal Business Name): IDCOKC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 S WESTERN AVE STE 4010
OKLAHOMA CITY OK
73109-3492
US

IV. Provider business mailing address

4221 S WESTERN AVE STE 4010
OKLAHOMA CITY OK
73109-3492
US

V. Phone/Fax

Practice location:
  • Phone: 405-644-6464
  • Fax: 405-644-6465
Mailing address:
  • Phone: 405-644-6464
  • Fax: 405-644-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JARROD LOUIS REES
Title or Position: ADMIN
Credential:
Phone: 405-644-6464