Healthcare Provider Details

I. General information

NPI: 1962586446
Provider Name (Legal Business Name): NIYAZ GOSMANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST ATTN:111C
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

1304 NW 170TH ST
EDMOND OK
73012-7410
US

V. Phone/Fax

Practice location:
  • Phone: 405-297-5903
  • Fax: 405-297-5934
Mailing address:
  • Phone: 405-297-5903
  • Fax: 405-297-5934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number23935
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: