Healthcare Provider Details

I. General information

NPI: 1457172058
Provider Name (Legal Business Name): MR. CEDRICK JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N LOTTIE AVE
OKLAHOMA CITY OK
73117-2051
US

IV. Provider business mailing address

812 NW 143RD ST
EDMOND OK
73013-1926
US

V. Phone/Fax

Practice location:
  • Phone: 405-600-3074
  • Fax: 405-605-8120
Mailing address:
  • Phone: 405-820-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: