Healthcare Provider Details

I. General information

NPI: 1285602235
Provider Name (Legal Business Name): MARY K GUMERLOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LINCOLN BLVD SUITE 400
OKLAHOMA CITY OK
73104-3252
US

IV. Provider business mailing address

1122 NE 13TH ST ORI236
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4912
  • Fax:
Mailing address:
  • Phone: 405-271-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number17547
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: