Healthcare Provider Details

I. General information

NPI: 1093257941
Provider Name (Legal Business Name): OKLAHOMA HEART CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 S WESTERN AVE STE 5020
OKLAHOMA CITY OK
73109-3445
US

IV. Provider business mailing address

5200 E I-204 SERVICE ROAD SUITE 304
OKLAHOMA CITY OK
73135
US

V. Phone/Fax

Practice location:
  • Phone: 405-644-5428
  • Fax:
Mailing address:
  • Phone: 405-644-5428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number24-129
License Number StateOK

VIII. Authorized Official

Name: FAZAL ALI
Title or Position: CEO
Credential: M.D
Phone: 855-541-2862