Healthcare Provider Details

I. General information

NPI: 1396208906
Provider Name (Legal Business Name): SARAH ANNE THEVATHERIL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 NE 13TH ST # 2300
OKLAHOMA CITY OK
73104-5008
US

IV. Provider business mailing address

940 NE 13TH ST # 2300
OKLAHOMA CITY OK
73104-5008
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2429
  • Fax:
Mailing address:
  • Phone: 405-271-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94-10019
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019022811
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number39657
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: