Healthcare Provider Details

I. General information

NPI: 1922262047
Provider Name (Legal Business Name): OKWA PEDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 N SHARTEL AVE STE 606
OKLAHOMA CITY OK
73103-2400
US

IV. Provider business mailing address

1211 N SHARTEL AVE STE 606
OKLAHOMA CITY OK
73103-2400
US

V. Phone/Fax

Practice location:
  • Phone: 405-235-9955
  • Fax:
Mailing address:
  • Phone: 405-235-9955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number12461
License Number StateOK

VIII. Authorized Official

Name: WAZIR S AHMAD
Title or Position: OWNER
Credential: MD
Phone: 405-235-9955