Healthcare Provider Details

I. General information

NPI: 1851868863
Provider Name (Legal Business Name): OKC KIDS UROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2018
Last Update Date: 10/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 NW 63RD ST STE 211
OKLAHOMA CITY OK
73116-1937
US

IV. Provider business mailing address

11 E 23RD ST
EDMOND OK
73013-4404
US

V. Phone/Fax

Practice location:
  • Phone: 405-823-0708
  • Fax:
Mailing address:
  • Phone: 405-844-5221
  • Fax: 405-340-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA MCKENZIE
Title or Position: CLINIC MANAGER
Credential:
Phone: 405-844-5221