Healthcare Provider Details

I. General information

NPI: 1043202096
Provider Name (Legal Business Name): TERRY NIZO COPELAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 03/30/2006

III. Provider practice location address

721 NW 6TH ST #200
OKLAHOMA CITY OK
73102-1205
US

IV. Provider business mailing address

1225 W MAIN ST #205
NORMAN OK
73069-6824
US

V. Phone/Fax

Practice location:
  • Phone: 405-553-1540
  • Fax: 405-553-1538
Mailing address:
  • Phone: 405-292-5500
  • Fax: 405-292-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15713
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: