Healthcare Provider Details

I. General information

NPI: 1083618003
Provider Name (Legal Business Name): KEITH JOHN KASSABIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST SUITE 2200
OKLAHOMA CITY OK
73102-1068
US

IV. Provider business mailing address

608 NW 9TH ST SUITE 2200
OKLAHOMA CITY OK
73102-1068
US

V. Phone/Fax

Practice location:
  • Phone: 405-231-3737
  • Fax: 405-272-6144
Mailing address:
  • Phone: 405-231-3737
  • Fax: 405-272-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number16576
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number16576
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: